Employers who offer lower health insurance premiums as an incentive for workers to lose weight might do better to try an alternative approach, a University of Pennsylvania study suggests.
 

 

Metastatic non-small cell lung cancer is an incurable disease. Despite this, over 2/3 of patients with this cancer who are receiving palliative chemotherapy, which is intended to reduce symptoms and improve quality of life, report that they believe such treatment may cure their cancer. Similar predictive errors can be found across a wide range of health care decision makers, including asthmatics, family members of critically ill patients, and patients undergoing high-risk surgeries. These unrealistic expectations impair decision makers' abilities to weigh the relative risks and benefits of health care choices, thus degrading the decision making process. This is particularly worrisome in our current health care culture that places shared decision making at its foundation. Insights from behavioral economics may help identify the mechanisms leading to the formation of these errors and, ultimately, enable us to develop ways to overcome these misunderstandings.

 

Patients' engagement in health-promoting behaviors is often driven by their expectations of potential health outcomes. Errors in their expectations may reflect poor physician-patient communication, psychological self-protection as patients or their family members confront a health threat, or both. The difficulties of predicting future mortality, illness burden, and accompanying emotions limit patients' abilities to make decisions that promote health. Optimism is the typical direction of these predictive errors, reflecting unrealistic hopes. Such optimism, such as believing palliative chemotherapy can cure cancer, may lead to preventable patient distress when foreseeable, yet unforeseen, poor outcomes occur. A patient with metastatic lung cancer who believes a cure is possible is less likely to make choices which acknowledge and prepare for his or her impending decline in function and, ultimately, death. These neglected preparations may include those related to emotional, financial, or legal matters in addition to the health care choices made along the way. As such, optimistic patients are failing to be fiduciaries to their future selves.

 

While much of the clinical research using behavioral economics to date focuses on improving the daily behaviors of individuals to promote health (e.g., smoking cessation, eating and exercise habits, medication adherence), the same principles can also be used to approach complex shared decision making. For example, patients with lung cancer are often current or former heavy smokers. We know from prior work that heavy smokers are likely to have steep delay discounting rates. When facing lung cancer, this present bias is likely to change the way that these patients form expectations of future health states and the benefits of offered treatments, thus changing the way they make health care decisions. Therefore, clinicians need to provide information in a way that allows patients to select options that are matched to their true preferences. This first requires acknowledging that information alone does not overcome bounded rationality.

 

In the era of shared decision making and patient-centered care, we need to provide support to patients and family members making high-stakes decisions that are imbued with uncertainty. Prior attempts to develop and test supportive interventions have generally failed. At least in part, this is likely due to a failure to sufficiently incorporate the lessons behavioral economics has to teach. Extending the reach of behavioral economics to these complex health decisions will undoubtedly improve shared decision making. This is especially needed in those situations where shared decision making is at highest risk of failing to fulfill its promise of patient-centeredness: those in which patients and families experience extreme emotions and stress. In the face of suffering, a deft hand is required when communicating scientific evidence in a way that respects important aspects of our humanness such as hope and fear. Behavioral economics can provide the foundation for improving the quality of these decisions if we, as a community, are able to educate and advocate for its use among clinicians unaccustomed to the principles of decision theory.