BUSINESSES LIKE AMAZON.COM make it easy to find, buy and pay for products.
“In health care, we’re the anti-Amazon,” said Shivan Mehta, a gastroenterologist and associate chief innovation officer at Penn Medicine in Philadelphia, describing obstacles that prevent patients from accessing and keeping up with their health care. “To do anything, it takes 20 or 30 different steps of the process, and it’s very complicated and nobody understands it. Every click matters, so any time you reduce those steps in the process, we’ve seen that it increases uptake.”
Mehta spoke April 17 at the AACR Annual Meeting 2023 in Orlando, Florida, about how insights from behavioral economics, the study of the intersection between psychology and economics, can be applied to health care settings. Mehta said barriers in health care settings and the wider community can prevent people from getting recommended cancer screening and needed care.
As individuals who get health care, he said, “We have systematic biases in thinking that often prevent us from achieving our goals.” These include present-time bias, an attitude that gives greater emphasis to current costs and benefits than to those in the future; status quo bias, the preference for leaving things as they are instead of seeking out change; and social influence bias, the tendency to listen to and follow the lead of people around us.
“Choice architecture,” the way decisions are presented to us, can help overcome those biases and influence how and whether we choose to take an action. Mehta cited the Amtrak trip insurance form that pops up after a person buys a train ticket as an example. The form emphasizes the low cost and potential benefits of purchasing insurance and the potentially dire consequences of not doing so.
One way to increase the number of people taking an action, including getting cancer screening, is to require the participant to opt out of an activity rather than opt in. That is, a person must unclick a box on an online form to avoid taking an action rather than click a box to take the action. In a 2018 study of colorectal cancer screening published in the American Journal of Gastroenterology, Mehta and colleagues invited 314 patients to receive a mailed fecal immunochemical test (FIT). The participants were randomized to two groups: one had to opt in to receive the test and the other had to opt out to not receive the test. In the opt-in group, 23.1% of people agreed to receive the test, while only 2.5% of the opt-out group declined to receive it. Ultimately, just 9.6% of people in the opt-in arm completed the FIT screening compared with 29.1% of people in the opt-out arm.
In another study published in BMJ in 2021, Mehta and colleagues compared people receiving a letter about hepatitis C virus screening to a group receiving a letter and a lab order for the screening. In the letter-only group, 19.2% of recipients completed screening, while 43.1% of those who received the letter and the lab order did so.
Also speaking at the session was Kelsey Lau-Min, a gastrointestinal oncologist and researcher at the Mass General Cancer Center in Boston, who described using insights gleaned from behavioral economics to convince clinicians and patients that genetic risk testing is a good choice for patients when it seems likely they are at risk for an inherited cancer.
Christopher Manz, a medical oncologist and researcher at Dana-Farber Cancer Institute and Brigham and Women’s Hospital in Boston, talked about using behavioral economics principles to encourage clinicians to have what he called “serious illness conversations” with patients who potentially are nearing the end of their lives. He said research indicates that nudging physicians to have these conversations is effective if the prompts make it as easy as possible for the doctor to remember and schedule the talk and also provide feedback on the doctor’s performance.
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