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The default trigger in health care
Dan Ariely, author of "Predictably Irrational"
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TEXT OF INTERVIEW
Kai Ryssdal: Everybody's different in how we handle what life gives us. Some of us actively make choices that could change an outcome. Others might just let things play out, see what happens. That's what you might call the default to doing something.
With the president in Pennsylvania today talking up health care reform, we're going to look at how that default trigger might affect the decisions doctors make. And the tests that they then order for their patients. Duke University Professor Dan Ariely is here to help us do that. Dan, good to talk to you again.
Dan Ariely: Same here.
Ryssdal: All right, so let's define a term, I suppose, to start with. What do you mean when you say default?
Ariely: OK. So default is the option that we get when we don't do anything physically. OK. So whatever was decided before us is what we will continue doing. So if you think about savings, for example, if you have an automatic withdrawal from your checking account savings every month, that's the default. It'll happen without any action. On the other hand, if you don't have one of these drafted, a default is that you're not going to save.
Ryssdal: OK. So tell me about your research. What'd you guys do?
Ariely: There's a huge literature on defaults. I think one of the cutest papers is about pizzas. So imagine that I give you two menus. Some people I give a menu that starts with all the toppings. And the other menu starts with no toppings and you have to add toppings to it.
Ryssdal: All right.
Ariely: The default in the first one is that you'll get a fully-loaded pizza. The default in the second one you get pizza just with cheese.
Ryssdal: Right.
Ariely: What happens is that people end up with a very different number of toppings. People who started with the pizza with all the toppings end up with lots and lots of toppings. People who started with empty toppings basically get one or two, and of course the financial outcome for the pizza place is very different. But we wanted to look at this in the domain of physicians ordering tests. So if you go to the hospital these days, or to visit your physician, you will see that they have these electronic order forms. And they basically use those to order tests for you. And sometimes these order forms are empty, nothing is selected for them. The default is nothing, and they have to pick what they want to order. And sometimes some tests are preselected for them.
So we created scenarios in which we described to physicians some patients who arrived at the ER, and we asked them to decide what test to give them. And to half of the physicians we gave the fully-loaded options, like the pizza. And for the other half we gave them one that were empty, and they had to check which one they wanted to do.
Ryssdal: Now did this involve actual patient care because you can see how health care in this country gets so expensive, when you guys are doing a test like this.
Ariely: Yeah, it did involve actual patient care. But, of course, the implications are for actual patient care. These were actual physicians that were making hypothetical decisions, but you could imagine how the same thing would play out if somebody built that system.
Ryssdal: Sure.
Ariely: And the basic result was that in the empty set, physicians chose an average five tests. And in the full set, they chose an average 13 tests.
Ryssdal: Wow.
Ariely: And the difference was about $1,300 per patient. Right? So now if you think about it, these information systems are going to roll out into hospitals in all kinds of ways and I think they have tremendous influence on what the physicians will decide.
Ryssdal: All right, forget about costs for a second. This actually, it sort of influences what specific tests there are, right? Because you have, in essence, with this fully-loaded sheet, a recommendation for these tests?
Ariely: That's right. So one of the reasons for this effect of the default is that people read it as an implicit recommendation. They said that if somebody checked all of this for us, it must be the case that this is a good thing to do or something, I need to do. Or in the physicians' case, you could even imagine that they think if they don't do it somebody will go ahead and sue them. And as a consequence, this fulfillment system could have a tremendous effect on what tests eventually get executed.
Ryssdal: So is the moral of the story: don't get stuck in a rut, right? I mean, question what you do systematically.
Ariely: I think that's a very good moral. Right. So if you say, "How much of what I'm doing is just because I've done it before and that's a default versus this is the decision that I actually want to arrive at?"
Ryssdal: Dan Ariely. He teaches behavioral economics at Duke University. His book is called "Predictably Irrational." Dan, thanks a lot.
Ariely: My pleasure.
I think that a professional with a doctorate degree, and perhaps many more years of training in a specialty, is to be considered too focused in medical practice to allow a full menu or empty menu to be of consequence. What about that next yacht payment, ... er, or is that just applicable to auto mechanics? Oh, and consider the real possibility of being accused of, or even sued for, medical malpractice. My retired cousin was a gut surgeon, who paid $187,000 a year in premiums. Where do you come up with that kind of money? That's $90.60 every working hour or $15,583.20 a month. That's paid before he makes a dime! So, it's really a balancing act of testing enough to get a proper diagnosis, but not too much to be wasteful. We certainly don't want non-medical entities or governments calling those shots, do we?
A good piece, but your closing comments miss the implications. To achieve real change, it's not just a question of individual doctors questioning their practice, but to set up structural mechanisms to change the default option. That is, hospitals and other providers should be required to use the "no intervention" checklist and add tests to that, rather than the other way around. If we just rely on individual behavior we're not likely to see any significant change.
But the big question that Dr. Ariely fails to address, is which case yields better results. Do the physicians who default to 0 tests, miss illnesses or do the physicians who default to a full plate over test? This is the essential question. The metric of interest is illnesses cured per dollar spent.
Professor Ariely points out an interesting phenomenon and (at least in this brief piece) barely scratches the surface of interesting implications about physicians and our health care systems. For example, the study suggests:
1. Physicians do not, as a rule, practice evidence-based medicine, otherwise they would tend to order the same tests, more or less.
2. Physicians order a lot more tests than needed, but this is not limited to large 'panels' of blood tests. Add x-rays, CT scans, MRI's, medications and specialty consultations. Do the math, that's a lot of $$ wasted.
3. Ordering more tests than needed has other unintended consequences: sometimes the results are abnormal and lead to even further tests, and often nothing significant is found. The result: more $$, more risk, and more worried patients.
A last thought: the price charged for the extra tests is much higher than the cost of performing them, so ordering unnecessary tests provides higher profits to labs/hospitals and physicians, and usually relatively little value.
Robert, MD
Rarely mentioned is the learning curve for doctors: learning how to use a particular service to acquire medical records. Let's say you go to a physician and he/she decides to run a particular test. You had that very same test last month ... under a different health system. Unless the practitioner is familiar with the records facility, it is probably cheaper (quicker) to just order duplicate diagnostic procedures ... and, no, delegating such tasks to assistants is not an answer: it's just a good way to hide subtleties that, especially in cardiology, can be crucial.
And of course there is the inherent conflict of interest. If the hospital puts in more defaults and the hospital is also the owner of the laboratory doing the tests, their profit will increase. Who is watching the fox?
Curiously physicians can't do this anymore without oversight but hospitals can.
