David Asch on Behavioral Economics and Health: Designing Health Programs for Real People

At TEDMED 2018 David Asch shared how he advances individual and population health by improving how physicians and patients make decisions in health care and in everyday life, including the use of medical treatments and personal health behaviors. Watch his Talk “Why it’s so hard make healthy decisions” and read his blog post below to understand more about the role irrationality and predictability play in decision making and why behavioral economics is such a powerful tool in health.

Health programs are more likely to be successful if they reflect how real people make real decisions.

If everyone did what was in his or her own best interest, no one would smoke, everyone would wear seatbelts, and most people would skip dessert. The simple observation that plenty of people do things that they know in their hearts isn’t good for them is partly a story about the limits of human willpower. It’s also a story about the trap of assuming that people are rational. We fall into that trap when we believe that helping people understand how to improve their health is enough to help them actually improve their health. Often it isn’t. We often do things that compete with our own best interest not because we don’t know what to do, but because even though we know what to do, we don’t do it.

Do any of these examples sound like you?

Sally is at an event where chocolate cake is served for dessert. Sally knows that the cake will throw her off her diet, but it is right in front of her, and it looks so luscious and, well, the diet can take a break until tomorrow…

Joe knows that regularly taking his high blood pressure medication is one of the best ways to avoid the kind of devastating stroke that dramatically changed his father’s life. But as he heads to bed for the evening and realizes he didn’t take his medication, he decides not to turn around and head back to the medicine cabinet…

Sally and Joe have present bias—meaning that they pay more attention to the outcomes that are right in front of them (like that chocolate cake) than the even-more-important outcomes that are in the future (like losing weight). They aren’t alone. I have present bias, and so do we all.

Consider Reggie:

Reggie buys a lottery ticket on his way to work every day, and he always plays the same number. He dreams about what he’d do if he won, and although the odds are small, people win all the time. And he never misses a day because what if his number came up on just the day he missed buying a ticket!

Like Reggie, each of us sometimes overestimates small chances—focusing on the outcome rather than its likelihood. And each of us sometimes has regret aversion: we hate that feeling of missing out, that life would have been better if only we had done things differently. If only we had bought that stock when it was low. We all feel this way sometimes, just like we all overestimate small chances, and all focus too much on the present and not enough on the future.

Sally, Joe, and Reggie are not behaving in ways that best help them achieve their goals. But they are making the mistakes we all make.

So why do we continue to design tepid health programs based on a belief that people will do as they should? We do so because our first assumption is that people will behave with their own best interests in mind—that they will behave rationally. But often, we are irrational.

Behavioral economics is based on this recognition. We don’t always do what is in our own best interest. Our decisions are subject to emotion, to framing, to social context. But the key contribution of behavioral economics is recognizing we are irrational in highly predictable ways. It is the predictability of our psychological foibles that allows us to design strategies to overcome them. Forewarned is forearmed.

That’s why behavioral economics is such a powerful tool in health. For example, we can use behavioral economics to help people take their medications as prescribed. Perhaps we offer rewards to help them to do so—making the benefits of taking medicine seem relevant today, unlike the potential avoidance of a stroke years down the line. We can set up rewards in lottery formats because the difficulty interpreting small probabilities makes lottery incentives even more potent. We can make patients eligible for rewards only if they took their medicine the day before, harnessing the human tendency to avoid regret.

These approaches work because they see past how we would like people to make decisions and toward how they actually do so. They work because they hitch our health care wagon to the behaviors and mental approaches we already follow. They make the right choice the easy choice because they harness our own, predictable, irrationality instead of trying to compete with it.