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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Choices in Health Care Are Important and Hard To Get Right

There are few certainties in life, but you can count on these: death, taxes, and having to make a lot of choices about your health care.

Austin B. Frakt, PhD

(Image: Doug Levy)

From selecting a health plan to choosing a physician to deciding among various treatments, health care in the United States is all about choice. Studies show that in making these choices, mistakes are common, as is overconfidence.

Consider choosing a health plan. A typical Medicare beneficiary can choose from among about 20 Medicare Advantage plans and 30 or so prescription drug plans. A typical Affordable Care Act marketplace consumer faces a choice of 40 plans. At least half of all US workers have multiple options for employer-sponsored coverage. Some Medicaid enrollees have choices among managed care plans.

Choosing among these isn’t easy. For instance, many studies have found that a large majority of Medicare beneficiaries do not select the lowest cost prescription drug plan that would meet their needs. When people are offered assistance identifying cheaper plans or gain experience with the prescription drug program, many switch plans for better deals.

There’s evidence that the rest of us make mistakes too. The US Department of Health and Human Services found that more than 70% of returning Affordable Care Act marketplace consumers could have found a cheaper plan in 2015, yet only as many as 30% attempted to do so.

In an experiment by Eric Johnson, PhD, MS, of Columbia University in New York City, and colleagues, participants similar to those who shop for marketplace coverage were asked to choose the lowest cost plan from among just 8 choices. Only 21% were able to do so. Saurabh Bhargava , PhD, of Carnegie Mellon University in Pittsburgh, and colleagues studied workers at a firm that offered 48 health plans that were identical except in cost sharing and premiums. Most selected more expensive plans than they could have. For instance, many paid $500 more in a plan’s premium to reduce their deductible by $250, an objectively bad deal.

One reason consumers make mistakes is that they are misled by heuristics in which they are overconfidentOne analysis showed that consumers more readily avoid an increase in deductible than the same increase in premium, an indication of irrational thinking. Peter Ubel, MD, of Duke University in Durham, North Carolina, and colleagues asked people to select among hypothetical “gold,” “silver,” and “bronze” plans, but they reversed the meaning of “gold” and “bronze” for half of them. Most people picked “gold” regardless of plan characteristics, presumably because it sounded better. The labels misled.

Consumers make mistakes like this because they apply shortcuts that mislead—like assuming a plan label is informative of its generosity or quality. Pat Croskerry, MD, PhD, of Dalhousie University in Halifax, Nova Scotia, Canada, suggested clinicians may apply shortcuts, too, particularly when they are “hurried, distracted, fatigued, sleep deprived.” He continued,

[P]roviders must select strategies to maintain throughput of patients. One obvious strategy is to attenuate workload by using heuristics and shortcuts that achieve speed and frugality of cognitive effort….

Dr Croskerry cataloged 30 such heuristics, shortcuts, and biases applicable to clinical decision making. One is multiple alternatives bias, in which an increase in clinical options gives rise to irrational decision making, including greater preference for what might be considered the default or status quo option.

Donald Redelmeier, MD, of the University of Toronto, in Ontario, and Eldar Shafir, PhD, of Princeton University, in New Jersey, conducted experiments that illuminate multiple alternatives bias. In one experiment, family practitioners were presented with 1 of 2 scenarios involving a man with chronic hip pain. In one scenario, respondents were asked to select between referring the man to surgery only or to do so in combination with initiating ibuprofen. In the other scenario, a third option was added: surgical referral and initiation of piroxicam. When this third option was added, more respondents elected surgical referral only, relative to the 2-option scenario (72% elected surgical referral vs 53% elected surgical referral plus ibuprofen). Somehow, offering the option of another drug decreased the appeal of prescribing any drug.

Researchers at Rutgers University in Piscataway, New Jersey, found that accountability can strengthen multiple alternatives bias. In their experiment, physicians wrote down their decision-making rationale in preparation for future discussion. This increased their attraction to a status quo option when presented with 2 other options similar to each other, relative to a scenario in which they were presented with just the status quo and one of those other options. Gretchen Chapman, PhD, of Rutgers University in Piscataway, New Jersey, explained that this may occur because when there are 2, similar options, it’s hard to justify a choice between them, increasing the relative appeal of the dissimilar option (the status quo).

Like consumers shopping for health plans, physicians may be overconfident in their ability to avoid biases like this. Diagnostic error rates are as high as 10% to 15% in some medical specialties. Nearly half of care deviates from recommended best practices. Despite these findings, studies have documented overconfidence in diagnostic performance, and that confidence has little relationship or even an inverse relationship with diagnostic accuracy. For example, in one study, autopsies showed that 40% of diagnoses judged to be “completely certain” were incorrect.

At least in broad outline, what works for consumers in health plan markets may work for physicians in the examination room. Experience, training, and decision support tools have been shown to improve consumers’ ability to choose health plans better suited to their needs.  There’s evidence suggesting  that educating physicians about the biases they are subject to would improve decision making, as could greater reliance on evidence-based medicine. More experience—even with simulated cases—and statistical training may also reduce errors. Finally, in some areas, automation and checklists may help. Researchers have found evidence that the layout and grouping of treatment options within decision support systems can help guide primary care providers to more clinically appropriate choices.

Choices pervade our world. Some of the most difficult ones arise in health care and its financing. To various degrees, consumers of health insurance, patients, and even physicians are overconfident in their ability to make the best choice. Recognizing that we make mistakes, that we are overconfident in our ability to avoid them, and availing ourselves of the training and tools that can help do so are sensible steps forward.

About the author: Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.