Patient engagement and shared decision making are two sides of an approach to improving health care delivery that relies on motivating patients to pay attention to their health, providing them with ample information about health and treatment options and encouraging discussions with providers about those options. The underlying hope is that patients will make “good” choices, which theoretically will save money and that by generally paying more attention to their health, patients will be in better health and incur fewer expenses. Sounds good, but will it really work across the large pool of American patients, who have varying ability to be engaged and to make good decisions. An article in Health Affairs suggests an alternative approach. (HA Article) The authors basically propose that “choice architecture”, which in essence pushes consumers in a certain direction, is a better way to get desired behavior than engagement is. They first lay out several issues they see with the engagement strategy, including that getting people to pay sustained attention to anything is hard and that getting people from “intend to change” to actually changing behavior is very difficult. The authors suggest that choice architecture, which guides decisions in a certain direction, may be a better way to get to the same outcomes, at least for some health care decisions. A well-known example would be requiring consumers to opt out of certain choices, as opposed to having to opt in. The authors review research that requiring opt outs significantly increases the percent of people going down the desired path, for example, using generic drugs, or mail delivery of drugs. While this appears to be a reasonable approach, it feels manipulative, and that may undercut respect for the individuals involved, as opposed to shared decision-making, which at least has as a nominal value the honoring of personal values and preferences. If choice architecture is used, perhaps patients should be informed that it is being used and why.
