Bahavioral-Based Design: Pay Attention to the Tension

Behavioral-Based Design: Pay Attention to the Tension

How effective are corporate wellness programs?

While corporate wellness programs are flourishing, the jury is still out on their effectiveness.

Wellness proponents have been encouraged by the advent of value-based insurance design (VBID). This approach does two things: 1) Lowers (or eliminates) copays and coinsurance for certain medications and preventive services (high value) that prevent or effectively manage disease, and 2) Increases copays, coinsurance or other payments for hospital-based and higher-cost (low value) services.

VBID has been shown to increase medication compliance and the use of preventive services. But is the investment achieving the cost savings and health improvement long sought after?

Regarding cost, an article in the February 2010 issue of Health Affairs (1) suggests that one employer’s value-based insurance design “broke even” by reducing non-drug health care services that offset the increase in drug spend. While the study did not include the cost of implementing the program, it did provide some support for the continued use of VBID approaches to manage cost.

What about improving health and reducing health risk? This is a thornier question because it relies on two things…you and me. Are we willing to change our behavior to improve our health, and if not, what then?

Incentives have also been a popular approach to get people’s attention. But how effective have incentives been? A recent survey by Buck Consultants (2) estimates that only 19% of employers believe that incentives are “effective or extremely effective” at changing behavior. At the other end of the scale, 48% of respondents said their incentive programs were “minimally effective”, “not effective”, or “don’t know”.
With little concrete evidence of wellness program success, and the perceived ineffectiveness of incentives, what can be done to successfully lower cost and improve health through wellness?

Behavioral-Based Design

Behavioral-Based Design (BBD) is an emerging concept centered around one key driver…managing “tension” to motivate action. The “tension” driver is derived from much of the behavioral economics research related to human biases, particularly social bias, loss aversion, inertia, present bias, and statistical optimism.

In the VBID approach, reducing financial barriers certainly encourages people to obtain and take their medication as prescribed. And it encourages people to seek out care to treat and preventive disease. But the lack of an increased level of tension is the main reason that even these approaches are not changing the behavior of the vast majority of people. While it’s great to pay less…or nothing…for prescriptions and preventive care, evidence shows us that many people still don’t take the action to change their behavior. Incorporating more “tension mechanisms” in VBID will help to improve the success and effectiveness of these programs.

Incentives, though widely used, also rarely increase tension. Why? The incentive amounts are usually not high enough to get someone’s attention. Most employers are offering annual incentives in the $100-$250 range, according to the Buck Consultants Global Wellness Survey. In a rational world, pocketing an extra $100 should be a no-brainer. Yet people leave money on the table all the time, often due to inertia, the strongest of the behavioral biases.

Pay Attention to the Tension

How does BBD manage tension to motivate action? Let’s consider a few examples:

Safeway introduced their “Health Measures” program a few years ago. The design had its roots in the basic tenets of behavioral-based design. Under the program, if you take certain actions and reach certain thresholds, you can earn an incentive up to $1,300, or up to $2,600 if your spouse participates and reaches those same thresholds. Does $1,300 or $2,600 get your attention? Yes, because it raised your level of tension. $100 may not get your attention, but 13x that does, as it did for 85% of the employees eligible for the Safeway program. The learning is that incentives should be meaningful enough to get attention and motivate action.

AmeriGas requires employees to obtain periodic medical exams. If you don’t, you lose your employer-provided health insurance. Compliance is high…because tension is equally high. Mandates increase tension and get people’s attention.

Let’s take another example: On-site fitness centers. Do they pass the “tension” test? No. Fitness centers are a wonderful benefit, and many employees benefit from the corporate investment in on-site centers. Yet without a “tension mechanism” in place to motivate the majority of the workforce to act, usage will be limited to a small percentage of the workforce.

What about corporate “challenges?” Do they meet the “tension” test? Yes. People are influenced to a large extent by social bias. We like to “be in it together”. That’s why corporate challenges and The Biggest Loser have been wildly successful. Not because of the program itself. Because the program creates tension, which initiates motivation and action.

The tenets of BBD need to be aligned with your organizational culture and overall total rewards strategy. While this approach may not be for everyone, it should be considered as you look at benefits design changes for 2012 (yes…it’s that time time). As you reviewing new design alternatives, remember to pay attention to the tension and ask one question: “Will this provision raise tension to the level that people will act”

Measuring Behavior Change
Remember to track your results. Human behavior change can be easily measured. You should always pay attention to the success of your programs and practices. What participation, completion, and achievement goals have you set? Are they high enough to increase your own level of attention to achieve them? Are you meticulously tracking cohort groups who are achieving the desired goals, and the impact on health care cost, health risk, absence, disability, and productivity? Are you showing tangible results of the financial impact of your strategy and interventions? We need to be thinking about ways to dramatically increase the bar to initiate action, change harmful behaviors, and foster helpful behaviors in the effort to improve individual and organizational health that will lead to improved individual and organizational productivity and sustainability.

Bottom Line: Improving Health, Improving Life
The holy grail of health and wellness promotion is the ability to change human behavior to promote health and improve overall health risk. Only by increasing tension to motivate action can we get people to take the right steps to volunteer, participate, achieve and believe that they can improve their health and live a long and healthier life.

Remember: Pay attention to the tension.