Irrationality: Looking at nonadherence through the lens of behavioral economics

Call it the triumph of irrationality over self-interest.

Healthcare experts and pharmacy leaders have been grappling with the challenge of patient nonadherence for decades. They’ve spent countless hours trying to understand why patients often don’t act in their own therapeutic best interests, even when they know the health risks they incur by failing to take their medicines as prescribed.

Pharmacy operators, in partnership with drug manufacturers, health plan payers, accountable care organizations, insurers, technology vendors, colleges of pharmacy and other health stakeholders have thrown an arsenal of automated tools, ideas and systems at the problem — automated refill reminders, personal follow-up by phone, medication synchronization programs, dosage-timer devices on pill bottles, etc. — with mixed results. The path from prescriber to proper drug utilization by patients, all the way through to the end of the medication therapy, is still fraught with pitfalls.

IMS Health calls it the “leaky bucket challenge,” and acknowledges the path to improved adherence is steep. This, despite the fact that most patients have been warned often enough and are aware of the risks nonadherence can pose to their long-term well-being and, in some cases, to their long-term survival.

So what’s going on? Some of the answers to the nonadherence puzzle can be found at the intersection of economics and psychology, in the science of behavioral economics, said Douglas Hough, PhD, associate scientist and associate director of the Master in Healthcare Management program at Johns Hopkins University’s Department of Health Policy and Management in the Bloomberg School of Public Health.

Established as a formal discipline only three decades ago, the theories behind behavioral economics help explain the gulf between rational and irrational behavior. And they could point the way to some promising approaches to improving medication adherence.

“People aren’t always rational,” said Hough, author of “Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why.” “They may not act rationally in their own self-interest.”

That includes not filling newly written prescriptions, or failing to take medicines that are critically important to long-term health even after filling the script. “Patients are only filling 75% of the scripts they’re getting,” said Hough, who spoke at this year’s World Congress Summit to Improve Adherence and Enhance Patient Engagement. As for why, he added, “A standard economist would say, ‘They cost too much,’ or ‘There’s not a pharmacy nearby.’”

“Those are issues. But ... if you take those issues away, there are still a lot of people who are not adherent,” the economist said. Behavioral economics provided some reasons why, by taking into account psychological factors and ways of thinking — often subconscious or automatic — that people frequently employ.

“Standard economics ... assumes that everybody is rational — that they know what their preferences are, that they have full in formation, and ... that everybody knows what they want, and that they go about getting it in a deliberate, thoughtful, logical way.”

“Behavioral economics says, ‘Not so fast,’” Hough said. “People are going to do things that a truly, full-time rational person would not do.”

Hough said all human beings employ both “System One” and “System Two” modes of thinking, a concept advanced by behavioral economist Daniel Kahneman, winner of the 2002 Nobel Prize in economics.

“System Two is the standard economist’s view of how people think: It’s deductive, deliberate, thoughtful; it takes a while; and it’s self-aware,” Hough said. “Economists for 150 years have presumed this is how people make decisions. But there’s also System One, which ... is automatic thinking with rapid decision-making.”

System One thinking, Hough said, is “like driving a car; it’s just automatic. You know how to process the information.”

“With medication adherence, it’s incumbent on the profession to figure this out,” he said. “For the most part, taking medications is a System Two function. It involves rational, deductive thinking and ... uses a lot of energy.”

“If, somehow, you can convert medication adherence to System One thinking, you’ve now made it easy. You’ve made it a habit. You just do it, like going to Star-bucks in the morning. You make it automatic,” he said.

To encourage patients to adhere to their drug regimens, Hough added, pharmacies also are going to have to counter what economists call “hyperbolic discounting.” The term refers to the tendency of most people to “discount the future ... at a much higher rate than economists expected.”

“People really prefer the present to the future,” Hough said. “It makes it tough to encourage adherence because certain illnesses are asymptomatic, like high blood pressure or high cholesterol, in which you see the cost of taking the med, and the time and bother of opening up the pill bottle every day, and you don’t see any results. There’s no salience to it, as opposed to taking something like Celebrex or ibuprofen, where you feel better.”

“The thing to do is find a way to emphasize the short-term benefits of adherence,” Hough said. “It’s telling patients, ‘Here’s why your life is going to be better if you’re adherent to your medication, and not just because you’ll live a couple of years longer.’ The challenge is defining short-term benefits for drugs that truly have long-term benefits and that to the patient, have few short-term, salient benefits.”

“That’s why behavioral economics is not a magic bullet,” Hough said. “This is not going to take medication adherence from 50% to 100%. The best we’re trying to do is ‘silver buckshot.’”

One finding of behavioral economics that Hough said could be effective as an adherence tool is the concept of loss aversion. “People really hate to lose. In fact, if they lose ‘X,’ they’ll feel twice as bad as if they had gained ‘X,’” he said.

That means that the stick may be more effective than the carrot as a mechanism for getting patients to adhere to their medications. “How we can use that is ... through the concept of a commitment device,” Hough said. “If patients have skin in the game, they’re going to be more committed to action than if they don’t.”

One such commitment device, he said, could be giving patients “an amount of money or a reward for being adherent. And if they aren’t, they’ll have to give the money back.”

Another potential adherence mechanism, Hough said, is “the power of the default.” For instance, establishing a default system through which people are automatically opted in for organ donation when they apply for a driver’s license — a system practiced by most European countries — as opposed to the default opt-out donation system in the United States, in which applicants have to check a box to agree to donating their organs.

In the pharmacy arena, that could apply to the automatic 90-day script renewals generated by some pharmacy benefit managers who operate mail-order pharmacies for their members. In those cases, Hough said, “The default is the drugs come unless you tell them to stop. It improves adherence.”

“We have enough evidence that these things work — not 100% of the time — but they’re most likely to move the needle on adherence,” Hough said. “These are some levers you might want to consider using.”

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