Researchers at Carnegie Mellon University, the University of Pennsylvania, Aetna Inc. and the Philadelphia Veterans Affairs Medical Center believe that this approach can counter one of the underlying causes of major health problems in the United States and other developed nations — bad decision-making on the part of individuals. Carnegie Mellon is a private research university with a distinctive mix of programs in engineering, computer science, robotics, business, public policy, fine arts and the humanities. Carnegie Mellon provides an education characterized by its focus on creating and implementing solutions for real problems, interdisciplinary collaboration, and innovation.

Individual behavior plays a central role in the disease burden faced by society. Many major health problems in the United States and other developed nations, such as lung cancer, hypertension, and diabetes, are exacerbated by unhealthy behaviors.

Modifiable behaviors such as tobacco use, overeating, and alcohol abuse account for nearly one-third of all deaths in the United States. Moreover, realizing the potential benefit of some of the most promising advances in medicine, such as medications to control blood pressure, lower cholesterol levels, and prevent stroke, has been stymied by poor adherence rates among patients.

For example, by 1 year after having a myocardial infarction, nearly half of patients prescribed cholesterol-lowering medications have stopped taking them. Reducing morbidity and mortality may depend as much on motivating changes in behavior as on developing new treatments.

Tobacco use, obesity and alcohol abuse account for nearly one-third of all deaths in the United States. What’s more, the full benefits of many medical advances — such as medication to control blood pressure, lower cholesterol and prevent strokes — go unrealized because people fail to adhere to their treatment.

So, why do people make choices they know are bad for them, or fail to do things, like take medication, which they know will be helpful?
 

Take weight loss. Many of us, around the holidays, resolve to lose weight starting after the New Year. But when the time comes, many people fail to make good on this resolution.

Rather than a simple lack of willpower, the scientists explain that this is an example of a present-biased preference: the tendency of individuals to place disproportionately greater weight on the costs and benefits of their choices in the present than in the future.

The cost of giving up food one enjoys is immediate, while the benefits are realized in the future. Without a mechanism to enforce self-control, a person’s resolve often fails.

Another common decision-making bias is the tendency to favor the status quo or default option. This bias explains, for example, why the organ donation rate in the United States is so much lower than in France, where almost everyone is an organ donor. In the United States, a person must sign-up to be an organ donor, but in France, a person is automatically registered as a donor unless they choose to opt out.

These biases can be exploited by making the healthiest choice the one that follows the path of least resistance. For example, fast food restaurants that now offer soda as the default choice with a combo meal can instead make a bottle of water the default option, with soda being a substitution available only on request.

A cafeteria line could be arranged so that the healthiest foods appear first, with unhealthy foods requiring the most effort to select. Employers can provide chilled bottles of water within easy access of workers, while placing soda machines in out-of-the-way locations. Vending machines could be installed in workplaces with access codes that an individual must activate to buy snacks or soda on the following day.

Present-biased preferences, meanwhile, can be utilized by providing patients with up-front rewards for healthier behavior. Such incentive-based approaches have been found to be effective in areas such as smoking cessation and even abstinence from drugs such as cocaine.

“We’ve only scratched the surface of potential applications. The possibilities for using decision errors to improve health behaviors and thereby improving the health of the population is enormous,” said study author George Loewenstein, the Herbert A. Simon Professor of Economics and Psychology at Carnegie Mellon.

Asymmetric paternalism can be used to help people get better medical care, give up bad habits such as smoking, or even exercise more. Gym visits or routine lab tests, such as cholesterol screenings, can be automatically scheduled so that the patient has to incur added inconvenience to cancel them rather than, as is currently the case, to schedule them.

People often miss out on routine but life-saving medical tests simply because they fail to schedule appointments. Health care providers should automatically schedule the next test when the patient comes in for the current test.

The potential for these approaches to improve health is immense, and some of the up-front costs of incentive programs could be paid by employers or insurers in anticipation of improvements in health and productivity that likely would follow.

As the American researchers underline, modifying health behaviors such as smoking is an enormous and important public health challenge. Despite tremendous progress, smoking still causes more than 400,000 preventable deaths per year. But these approaches have the potential to be more effective than many approaches that have been used to date.