health behavior change

A rise in E.R. visits explained by brain & behavior

The Wall Street Journal recently published a story that ER visits are on the rise despite rollout of the Affordable Care Act. 

Lawmakers wanted “to give the uninsured better access to primary-care doctors who could treat routine ailments and prevent chronic disease, with the intent of keeping patients out of the ER and lowering the cost of care”….but “Instead, the ER doctor group’s research and several other recent studies suggest that people who gain private and government insurance are more likely to seek emergency care.”

Of course we can point to a lack of sufficient primary care providers – we do not have enough here in the U.S. to handle all the newly insured. However, here’s a different perspective on why people are still seeking care in the ER:

Most uninsured people go to the ER when they need medical care. This is their habit. Because for years in this country, without health insurance, you could still seek medical attention in the ER. A habit is very difficult to break. In fact, an established habit is harder to break than forming a new habit is to make.

When you do a new behavior – let’s say, cook a meal you have never cooked before – your brain works hard to think about how to do it…how to follow the recipe, what temperate to set the stove at, etc. All that thinking takes place in the front of your brain, the prefrontal cortex. Keep in mind, the human brain is 1 – 1.5% of a human body weight, but takes up to 25% of the energy a human body produces to work. So any time you do something new, the brain function related to that new behavior consumes a lot of energy in the prefrontal cortex.

Once that behavior becomes familiar – meaning, you can cook that meal so easily you don’t need to think about the details – that thinking moves into the habit center of the brain, the striatum. Cooking that meal then becomes your habit. Habits, or defaults behaviors, are strongly wired in the brain and require little energy to maintain. This is why eating behaviors are so hard to change.

As we are learning, giving health insurance to people who are in the habit of seeking care in the ER will not be enough to break their habit. Going to the ER is their default behavior. I would bet that instead, they figure they can continue going to the ER and be covered. Their habit will now be paid for. These folks will not learn a new habit of going elsewhere until we design obvious and easy pathways for them to develop a new habit around seeking care.

Learning to go to a primary care provider is a new behavior for the uninsured who are now insured. Which means as health care designers, we need to figure out how to effectively tap into the prefrontal cortex of millions of people. I’d say we have important work to do!



Healthcare towards 2014

As we continue to digest the U.S. Supreme Court rulings last week, here is a snapshot of how I am digesting it all.

Mandate: Every US citizen must have health insurance and if not, we get penalized in the form of a tax. It’s not an enforceable tax (nor is it very much money) so unfortunately, many people will opt not to purchase insurance – this is a weakness in the economic model. (more…)


Designing for persuasion is an exciting and challenging task. BJ Fogg is constantly refining his persuasive design process, and as members of his Persuasive Tech Lab, we have opportunities to practice this methodology. Always best to do this persuasive design process with a team that knows your target users. I use this methodology for projects related to habit design and health behavior change. (more…)