Behavioral Science Workshop: Working with Centene to Improve Patient Care

Medical professionals live busy lives, so when the folks at Centene decided to come to a behavioral science workshop for two days, we wanted to make sure the visit was well worth the effort. It went so well, we thought we’d share some highlights to give our readers an impression of what work we do at the Center for Advanced Hindsight (CAH) and the kind of activities that can be expected from one of our workshops. 

First, a little about our partner. Centene is a diverse, multi-national healthcare enterprise which works with government sponsored healthcare programs, focusing on under-insured and uninsured individuals, to provide a wide range of services and health insurance coverage. Since its inception in 1984, Centene has grown to become a Fortune 500 company that services 32 states in the US and 3 international markets, managing care for over 15 million members. As part of their innovative mission, they’ve partnered with the Center for Advanced Hindsight (CAH) to utilize behavioral science techniques to continue improving their services for the health and wellbeing of their members.  

The goal of Centene’s visit to CAH was to get a glimpse of how we conduct research using the principles of behavioral science and to share ideas that align with their research interests going forward in order to maximize impact. To this end, we created two days of talks, activities, and discussions around some of the research we’ve conducted, highlighting major factors that contribute to health-related behaviors and some of the difficulties people face when making decisions about their health. 

 The visit began with Dan Ariely, a founder of the Center for Advanced Hindsight, and Professor of Psychology and Behavioral Economics at Duke University, providing an overview of behavioral economics and the science behind behavior change. Dan discussed the two main concepts of friction and fuel, and how these two forces interact in one’s environment to affect the likelihood of engaging in any specific health behavior. As an example, friction is anything that makes a behavior, like eating healthy, more difficult to do. Friction can manifest in many ways, like not having the healthy foods at eye level in the refrigerator, or not having those foods already prepared and ready for consumption. By removing friction associated with engaging in healthy behaviors, while also increasing friction associated with unhealthy habits, Dan discussed how research shows dramatic improvements in various health-related behaviors. In discussing the other main concept of fuel, which is the various ways in which we can boost health behaviors through incentives, Dan discussed reward schemes available that impact people’s success. For example, sometimes offering monetary incentives are less effective than providing social support. 

(Dan Ariely sharing his experiences with behavioral science approaches to healthcare)

After Dan’s opening talk, a few of us researchers at CAH gave presentations to discuss the various projects we were conducting that were relevant to Centene’s mission. These included both patient-side and provider-side interventions. On the patient side, our first talks provided an overview of the various digital tools for behavior change and apps for improving disease management. These are hot topics in behavioral science due to the dramatic increase in telehealth and digital health apps available in today’s market, as well as the great potential for these tools to transform the healthcare world and to reach many people who may not otherwise receive healthcare aid. 

Other talks discussed the barriers and potential solutions around getting people to adhere to taking their medications on time and as directed. Taking medication is often a reminder of illness, which can lead to avoidance. This can be counteracted by helping patients add visible reminders to their environment and having them think about how taking medication relates to larger goals, like spending time with one’s family.

Finally, we discussed some fascinating research uncovering a relatively novel concept of breaking points, which are moments in people’s lives where the stressors become too great and lead to unhealthy behaviors. Someone trying to adhere to a diet, for example, may decide to eat pizza one day when they’ve experienced a lot of stress, thereby breaking their diet behavior. These breaking points have shown to be a major contributor to overall breaks in healthy behavior goals, and can sometimes derail a person completely from their initial health plan. 

(Jenna Clark (Senior Behavioral Researcher on the Health Team) presenting breaking points research)

In addition to talks given by our behavioral scientists, Karyn Quinn, Senior Director at Centene, gave a talk covering behavioral science successes at Centene in the previous year, as well as goals for the upcoming year. The partnership between Centene and CAH focuses on three fundamental elements of care — appropriate utilization of health services, managing chronic illness, and every day health behaviors to improve mental and physical well-being. For appropriate utilization, she discussed materials meant to help decrease unnecessary Emergency Room usage by giving people the necessary information to make an informed decision while also providing them with alternate defaults to the ER (e.g., a nurse hotline or an urgent care facility.) For chronic illness, she presented work that Centene has done to encourage those with chronic illnesses to take part in their free care management phone service. Finally, she discussed how flyers that took a social norms approach to promoting the importance of flu shots (e.g., “You’d do anything to protect your baby, right? So be among the millions of moms who will get a flu shot this year.”), outperformed other flyer types. Finally, Karyn focused on future directions, aiming at a large-scale intervention to help improve physical and mental well-being.

During the workshop, we also focused on provider behavior. Two talks focused on physician behavior, demonstrating how physicians can fall prey to the same types of biases (e.g., anchoring, framing) as non-physicians, and how even though physicians have greater knowledge regarding health as compared to non-physicians, they tend to make similar decisions in the health-care context. These talks reinforced the importance of designing a healthcare environment that helps both physicians and patients avoid predictable errors in decision-making. 

We took a break from the talks to work together on an activity where we showed the Centene folks how to improve the quality and formatting of a customer feedback survey. Oftentimes, these forms can be challenging for customers to fill out, as they may ask confusing questions, or format the questions in an unnecessarily complicated way. When surveys are not constructed to be easy to read and answer, it creates friction, which inevitably reduces the likelihood that a client will complete it. We chose a form that had been used in a previous survey to edit together and, working in small groups, came up with a variety of solutions for improving the overall quality of the survey. A few things that stood out, from a behavioral science perspective, were the framing of the questions, the need for personalization wherever possible, and taking care in formatting Likert-style questions. When we finished, our new form looked like it had gotten a makeover, and everyone was energized to begin the final presentations.  

 

(Nina Bartmann (Senior Behavioral Researcher with the Health Team) showing how to make a good questionnaire)

After the talks for the day finished, we ended the day’s activities with a scavenger hunt where we had set up a handful of tables displaying a few hands-on interventions from previous research as well as some prototypes meant for future testing. One example of a physical intervention was an alarm clock with wheels that rolls away when the alarm goes off — forcing you to get out of bed to turn the alarm off. More recent prototypes focused on areas more relevant to Centene, such as reducing unnecessary Emergency Room visits and improving workplace health by reducing the amount of time individuals stay seated in meetings (as these interventions are still in development, we will go into more detail about these physical interventions in future blog posts).

 Although the behavioral sciences have provided us with many tools for solving big problems, these tools cannot be implemented in a vacuum. This is why it is so crucial to have partners who are willing to take the time to supply their expertise and provide a concrete context for the environments in which the problems we collectively would like to solve exist. Our workshops provide a space for these discussions to take place, where we can really zero-in on the most important problems and develop behavioral science-informed approaches to solve them.

Are you interested in the partnership on health and healthcare? Contact Becky Reeves, Senior Behavioral Researcher, at rebecca.rayburnreeves@duke.edu 

Is your organization in any other way interested in CAH Health? Contact Jan Willem Lindemans, Principal, at jan.lindemans@duke.edu