A Brave New World Of Health Insurance Choices

Christopher Goldsmith of Sibson Consulting’s provocative article written for the Society for Human Resource Management (SHRM) explores how behavioral economics can help guide decision making with the complex choices consumers face in selecting better health plan options. This article summarizes that information.

The Problem: Choice and Complexity

Health care reform means more choices for consumers and a more complex decision process than before. Senior citizens will now need to make choices each and every year regarding their Medicare coverages: whether to enroll in traditional Medicare, supplement it with a Medicare supplement policy and a Part D prescription drug plan, or enroll in a comprehensive Medicare Advantage plan instead.

Health insurance marketers face the challenge of guiding consumers through a fundamentally more complex decision process in a way that helps them make more informed and better choices. The most important questions marketers face are:

  1. How to help simplify a complex decision process for the consumer.
  2. How to empower the consumer to make the best choices.
  3. How to differentiate your company in a field of similar products.

Behavioral economics—the study of how people make choices, drawing on insights from psychology and economics—can be useful in designing and communicating employee health plans.

Rational vs Emotional Decision Factors

Decisions regarding health often involve irrational, or emotional elements, where behavioral biases cloud rational judgment. For example:

• Unhealthy Habits: Despite numerous public health messages, many young adults nonetheless choose to become substance abusers or overweight.

• Not Taking Advantage of Preventative Services: Even if they understand the value of preventive health care and preventive care services offered under their plans without deductibles, co-payments or co-insurance, many still fail to take advantage of free health screenings or physical exams available to them.

• Lack of Interest in Health Care Research: When making decisions about hospitals and surgeons, few consumers research data about hospital costs, mortality, readmission and hospital-acquired infection rates.

• Failure to Plan: When enrolling in Medicare, many consumers fail to research the options available to them that would assist them in making an informed decision.

Behavioral Economics and Open Enrollment

Understanding these behavioral tendencies enables organizations to create more effective communications and incentives to make better decisions that produce better outcomes. This is particularly important during the open enrollment process, to steer employees toward cost-effective health plan options. Organizations increasingly want employees to migrate from more expensive PPOs to consumer-directed health plans (CDHP), which have lower costs in exchange for greater employee cost sharing. However, Goldsmith points to three behavioral biases that impede this goal:

• Loss-aversion bias. People tend to overvalue the prospect of losing something of value and to undervalue the prospect of gaining something of value.

• Value system bias. Deeply rooted value systems and selective filters necessitate substantial evidence to the contrary or significant influence to effect behavior changes will change.

• Status quo bias. Inertia, or the tendency not to change, is especially significant when choices are complex.

Optimizing Choice Architecture

Reframing Experiment

Health plan participants considering  the 3 choices below are likely to resist moving from a PPO to a Healthy Living Plan or CDHP because of the potential loss of their current doctor-patient relationship while undervaluing the financial gains or the prospect of improved quality of care available through a rigorous provider selection process.

Original Enrollment Presentation

Choice Architecture

There are also behavioral biases that the organization could leverage in its open enrollment materials to better position the new product offerings that could result in better results. Designing communications in ways that appeal to these biases can put a new perspective on the choice that makes it easier for consumers to consider and evaluate their options.

“Choice architecture” describes how the various options are framed, ordered and explained.  Figure 2 below illustrates how the default option, order of the options, plan names, presentation of decision-making factors, and use of color elements can be used to influence choice:

Reframed Enrollment Presentation:


Preliminary testing with various focus groups show many people who chose the PPO Plan in Figure 1 subsequently chose the Healthy Living Plan or Thrifty Consumer Plan when presented with the design used in Figure 2. The expected result of this presentation of the data is better outcomes for the employees and the organization.

Incentivizing Lifestyle Changes

Sibson Consulting’s Healthy Enterprise Survey

Encouraging Wellness Program Participation: One increasingly popular way to promote more healthful lifestyle changes is by using incentives to increase participation in the organization’s wellness programs, as shown in the chart above from Sibson Consulting’s Healthy Enterprise Survey.  Studies have shown that, compared to a control group:

  • Sustained tobacco use quit rates are 3X as high among participants receiving incentives.
  • Obese participants tend to regain their weight when they stop receiving incentive payments.

Designing Effective Incentives: Sibson’s research finds that participation in an organization’s health risk assessment activities increases as the as the incentive value increases, but incentives must be well designed to achieve desired outcomes:

• Too low incentives fail to motivate behavior change.

• Too high incentives can create a “choking” effect that impedes performance.

• Too distant incentives lead people to devalue the reward.

 Too long a qualifying period encourages procrastination, and, as the deadline nears, the perceived cost of change magnifies resulting in lower participation.

 Misguided incentives cause the reward potential to crowd out the intrinsic motivation to focus on health.

• Too many incentive elements makes the complexity is overwhelming.

Using Behavioral Economics to Effect Change

In the preceding experiment, we examined how reframing the enrollment choices aided consumers in evaluating their plan choices.  In that example, two behavioral biases were considered in designing the enrollment material:

• Clue-seeking bias. When faced with complex decisions, people look for clues, which they hope will be relevant to rational decision-making.

The revised enrollment chart provided relevant clues like “thrifty” and “elite standards” to show how the plans would actually work for the customer: Providing discrete columns for the major benefits of each plan (ie. “Your annual payroll deduction,” “Company Deposit into your Account, ” etc.) allows the consumer to quickly pick up cues about the benefits offered.

• Framing bias. Because people make decisions within a larger context, they look to their experiences and the environment to establish a frame of reference.  Therefore, how choices are presented has a substantial influence on the decisions people make.

The original chart, by placing the PPO option at the top, appears to suggest that it is a default option, or a standard-bearer. The revised chart, by placing it at the bottom as a “Legacy Plan” counters some of the intrinsic biases that impede change mentioned above (loss-aversion bias,  value system bias, and status quo bias.)

Countering Behavioral Biases

According to Sibson Consulting:

Some behavioral biases can serve as bridges to better outcomes.

Sibson offers some examples of “countering” behavioral biases that can be used to help employees make more informed and considered decisions:

Marketing Applications

Marketers need to bear in mind that the enrollment materials they design have real consequences in terms of workforce behavioral bias, choice making and engagement. Marketers can use principles from behavioral economics to help customers make more rational decisions regarding their health and their health care benefits. This begins with taking a systematic look at those outcomes you’d like to effect, and the consumer choices that would enable them. The ordering of options, highlighting of decision factors, naming of programs, structuring of incentives and selection of defaults can impact the outcome of the enrollment choices that consumers make.