Two questions are front and center in pediatric health care:
-How do we enhance the ability of families and caregivers to make the “right choices” regarding their children’s health?
-How can we best contain the rising costs of health care?
Incentivizing behaviors and decisions that promote child health has the potential to achieve both of these ends. In this month’s issue of Pediatrics, Moseley and co-authors examine 82 beneficiary incentive programs designed to advance child health and implemented by Medicaid and the Children’s Health Insurance Program (CHIP). (10.1542/peds.2018-3161) These incentives typically include some form of material or service benefit that incur real time costs for these public payers, and the authors identify the following challenges in assessing the return on investment (ROI) for these programs: limited evidence on the health impacts of commonly incentivized behaviors, the delayed time horizon for measurable effects on health, and the need to identify meaningful proximal measures that allow for program assessment.
Dr. Jack Stevens is a clinical psychologist at Nationwide Children’s Hospital and provided a commentary (10.1542/peds.2019-0111) on Moseley, et al.’s paper. Given the associated costs and the uncertain ROI for these incentives, Dr. Stevens highlights several options that have the potential to change health-related behaviors and decisions, but without the resource outlay required of incentive-based programs. One of these options includes “choice architecture.” In medicine, choice architecture occurs when patient options are presented in such a way that influences the ultimate outcome. Several examples include: “opting out” of organ donations rather than requiring people to “opt in.”, and a default switch from name-brand to generic medication, unless prescribers specify otherwise. “Nudges” are used by choice architects to encourage favorable decision-making and outcomes.
Choice architecture would appear to be “low hanging fruit” in terms of low-risk and low-cost strategies with the potential to enhance choices that benefit health-related outcomes for children. This strategy can be readily implemented at the provider level and does not require payer involvement or a systematic overhaul. It is most effective when structured to essentially create paths of least resistance that lead families to those choices that best protect and promote their child’s health.
However, choice architecture often has paternalistic overtones, which may be problematic in an era where patient-centered care and shared decision-making are dominant foci for health care practitioners. I counsel parents on choice architecture as a parenting strategy, and I find it quite effective when parenting my own daughter, but I find implementing it as a decision-making strategy in my medical practice is quite challenging. Dr. Stevens’ commentary “nudges” me toward exploring methods for incorporating this no-cost technique into interactions with patients and families and is certainly a call for further studies comparing incentive-based programs with other methods for influencing caregivers and families in their decisions that impact children’s health.
