Behavioral science can help health plans achieve their goals by changing the behavior of members and providers, according to executives with Blue Cross Blue Shield of Massachusetts. They recommend that all health plans implement an internal "nudge unit," or a behavioral science resource to identify opportunities to incentivize certain decision-making.
The May 23 recommendation in Health Affairs was written by Mark Friedberg, MD, senior vice president of performance measurement and improvement at BCBS Massachusetts, and Michael Hallsworth, PhD, and Lila Tublin, who are employees of the Behavioral Insights Team, a London-based consulting firm.
About two years ago, BCBS Massachusetts established a permanent internal nudge unit, assisted by the Behavioral Insights Team and academic experts. They were inspired by the nation's first behavioral healthcare unit at Philadelphia-based Penn Medicine in 2016.
The BCBS nudge unit was established by convincing senior executives it was the right move through research from randomized controlled trials and explaining the unit as complementary to the company's existing strategies.
"We made it clear that we would be able to measure the efficacy of the nudge unit over time, since it would have a strong commitment to regular and robust evaluation. Leadership would have receipts to know if their investment was paying off," the authors wrote.
After senior leadership was convinced, the authors provided an educational program on behavioral insights for employees from key departments.
"In healthcare, a nudge might look like a reminder SMS text sent by a provider to a patient to schedule a follow up or changing the default option for a drug prescriber," the authors explained.
Before any real-world application of the nudge unit, the BCBS team defined the unit's operating principles: proposed nudges must require a clear business reason, and they must be able to be evaluated, so randomized designs are best. For transparency purposes, trial results should be shared internally, regardless of effectiveness.
The BCBS unit "includes identifying and assessing nudge opportunities, designing interventions with internal stakeholders, then testing and refinement."
The average timeline from idea to implementation is about eight to 16 weeks, but has been as short as four weeks. The unit is also sustainable because it targets key business priorities using business units' existing methodologies.
In the first two years, the BCBS unit has deployed 53 interventions across the company, including 25 randomized interventions to enable high-quality effectiveness evaluations. About half of the interventions targeted member decisions, and the other half targeted providers' decisions. There were final results for 14 randomized interventions, of which 12 "have produced effects in the intended directions."
Because the unit's work is quickly growing, the company hired a full-time nudge unit director in January who reports directly to Dr. Friedberg and who coordinates nudge unit efforts with each business unit.
The authors used colorectal cancer screenings as an example of how the nudge unit can direct changes in behavior. Because screenings were down during the pandemic, the company sent Medicare members free, at-home screenings. To encourage the use of the screening kits, the unit worked with a professor at the University of California, Los Angeles to develop a letter that would incentivize members to screen themselves. They cut the length of the original letter in half and added language that appealed to self-image. The changes resulted in 3 percent more kits being returned, or about 500 more kits.
The nudge unit has also incentivized voluntary submission of members' demographic information through mobile app changes and encouraged more providers to order statin prescriptions for diabetes patients by reworking language in letters sent to them.
Still, some nudges have resulted in decreased results of desired goals. The nudge unit "has plans to adjust or omit deadline language whenever we lack control over a communication's timeliness," the authors wrote about one trial's failure.