When the Affordable Care Act first rolled out, I wrote about the spike in emergency room visits. Omabacare, as a policy, is designed to do the exact opposite – lower unnecessary ER visits by providing more people with healthcare coverage. But as we are learning, when someone is habituated to receive the quick, quality care they need at a certain place (in this case, the ER), policy alone is not going to disrupt that behavioral pattern.
Leaders in the state of Utah suggested a plan to decrease ER visits. A plan that “will reward people for agreeing to stay out of the ER for non-emergency care, but also penalize them when they wind up there.” Utah lawmakers want to financially penalize people who go to the ER “unnecessarily.” But how many of us, when we need a doctor, know what is “necessary” and “unnecessary?” When you are terrified that your father has chest pain, or afraid your son may suffocate from an asthma attack, or scared because your baby has a fever….really!? Especially if you have experienced quality care in an ER before, of course it makes sense to go. And most people who are habituated to seek care at the ER are folks who were previous uninsured; people who have not paid for medical care. So suddenly they are going to pay a fine for going to get the care they needed to feel better?! What a terrible idea! As the article states, “you can’t fix ER overuse without addressing what’s causing the problem in the first place.”
I don’t know what the current status of the Utah law is, but we must take a moment to diagnose the problem before we enact a solution.
As systems engineer Dr. Peter Hovmand writes “how problems are defined has a lot to do with the solutions being sought.” Problem scoping and framing is critical to any design challenge.
When it comes to why people may unnecessarily go to the ER, here are three behavior design parameters you can use to define the problem:
1. What and how intense are the behavioral drivers to the ER?
What motivates people to go to the ER? Fear, confusion, worry? If so, they are making decisions with the emotional part of their brain.
What enables people to go to the ER? Convenience? Perhaps the ER is in close proximity. Familiarity? Maybe there is a friendly nurse who works there.
And how intense are these drivers?
2. How habituated are people to go to the ER?
How often and for how long have people been seeking care in the ER? Once per week or per month? For months or years? Or just once before?
3. What and how intense are the behavioral reinforcers to return to the ER?
What about an ER experience tells people to return when care is needed again? Perhaps the ER provides the comfort to calm the confusion. Again, how intense are these reinforcers?
Insights to these questions will help scope the problem. We must understand motivations and feelings to shed light on intervention design opportunities.