Author Archives: Lori Melichar

In the Search for Pioneering Ideas, Start With Other Fields

May 9, 2013, 8:00 AM, Posted by Lori Melichar

Lori Melichar Lori Melichar, director

As I prepared for a recent visit from the RWJF Board of Trustees, I reviewed our portfolio of grants that apply behavioral economics to perplexing health and health care challenges and reflected on what is pioneering about this batch.

These projects are all well-designed studies that, when completed, can inform policy development and result in behavior change. In the near future, policymakers, leaders of health care institutions, program officers, and clinicians will benefit from these nuanced findings about the applications of behavioral economics to health and health care.

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Behavioral Economics CFP: Low-Value Care? Why Now?

Mar 6, 2013, 6:58 PM, Posted by Lori Melichar

Lori Melichar Lori Melichar

To help those who want to respond to our recent Call for Proposals, Applying Behavioral Economics to Perplexing Health and Health Care Challenges, I sat down with Drs. Kevin Volpp and David Asch, co-directors of the Foundation’s Behavioral Economics Initiative at the University of Pennsylvania, to talk about low-value health care, why we are doing this CFP and what we are seeking from applicants.

Why are we doing this CFP now?

Kevin: There’s enormous concern about the growth in health care spending—both in the public and private sector. We can’t afford to keep increasing spending the way we have. But health care spending shouldn’t be defined as too high simply because it’s high. The question should be “How much value are we getting?” There is a widespread belief that there is too much health care that doesn’t provide value that’s commensurate with the costs—to individuals or to the government.

What’s particularly exciting is that, while health policy experts have acknowledged the problem of low-value health care for a long time, influential physician groups are becoming vocal about their belief that society would be better off — from both a quality and patient safety standpoint — if less of this care was provided. And they’re creating lists of health care services and procedures that they consider to be of low value that are available to the public.

Reducing use of low-value care is what’s going to be able to allow us to continue to fund high-value care for large portions of the American population.

What is low-value health care?

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New Call for Proposals: Pioneering Use of Behavioral Economics

Mar 4, 2013, 9:00 AM, Posted by Lori Melichar

Lori Melichar Lori Melichar

We have announced our second Call for Proposals in the field of behavioral economics. We’re actively seeking ideas that will help us to better understand how to discourage the consumption of low-value health services — those that provide more harm than benefit or which provide only marginal health benefits. In addition to improving health outcomes, this knowledge could contribute to lowering health care costs for us all.

Behavioral economics is an area of study by which I’ve personally grown increasingly intrigued and in which the Foundation has recently begun to invest.  We all know, for example, that we need to exercise, eat right and be actively engaged in our own health care. But we don’t always do what we know we should do; knowing the “right” decision to make does not guarantee that we make that decision. The goal of behavioral economics is to uncover insights that could enable people to make better — more “rational” — choices for their health.

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Eight Innovative Ideas to Influence Health Behavior

Apr 4, 2012, 11:30 AM, Posted by Lori Melichar

Lori Melichar Lori Melichar

The majority of my work in the Department of Research and Evaluation at the Robert Wood Johnson Foundation has been predicated on the long-held assumption that if you show people convincingly that doing one thing will create the outcome they desire, you can inspire behavior change. The problem is that when it comes to health, we consistently observe individuals acting in ways guaranteed to produce poor outcomes.

The observation of seemingly “irrational” behavior by economists, psychologists and others led to the development of the field of behavioral economics, which has, in recent years, produced insight to explain some of the perplexing health behaviors we observe in a way that the classical economic theories I learned in graduate school cannot. The Robert Wood Johnson Foundation believes these emerging insights have breakthrough potential to help people make better choices for their health. That’s why I’m excited to announce that the Robert Wood Johnson Foundation and Donaghue Foundation are now supporting a group of innovative researchers who are testing simple interventions that may have widespread impact on complex problems.

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Decisions, Decisions, Behavioral Economics and Behavioral Change

Oct 13, 2011, 4:33 AM, Posted by Lori Melichar

To improve people’s health, we ask them to change their behavior. Quit Smoking. Eat right. Lose Weight. Take a walk. Get your blood pressure checked. See a doctor. But, as many have noted, making a commitment to do the “right” thing is often easier than following through on that commitment.  In fact, many of the nation’s health epidemics are linked to people doing the “wrong” thing despite their best intentions.  Assuming that people want to feel good and live healthy, productive lives, how can we explain actions that unequivocally threaten that outcome?  As a classically trained economist, I am sorry to say: Classical economics can’t give us an answer to that question.  Wearing the hat of program officer with the Robert Wood Johnson Foundation’s Pioneer Portfolio, I’m charged with searching, often in unexpected places, for pioneering ideas that have the potential to accelerate change and radically improve our health and the health care we receive. This quest has led the Pioneer Portfolio to the doorstep of behavioral economics.

Unlike classical economics, which assumes people act rationally and make choices in their best interest, behavioral economics does not assume that people behave in ways that maximize their income or long term happiness and wellbeing.   Rather, behavioral economist study how various factors such as environment and psychology lead people to sub-optimal outcomes. Pioneer is seeking ideas from this field because we understand that, in addition to the social determinants of health that we cannot individually control, we are constantly making conscious and unconscious decisions that relate directly and indirectly to our health. We choose whether or not to take our medication. We select the foods we eat. We decide whether to take the stairs or go to the gym.  

When we interact with the health care system, our health care providers make decisions that impact our understanding of our health condition and our treatment protocol. Doctors decide whether to use positive reinforcement or fear tactics to motivate a patient, encourage her to stop smoking, or ask her to get a test. Nurses choose whether to speak up during rounds and how to impart knowledge to a patient when he is discharged from the hospital.  Insurers seek to influence our decisions with financial incentives related to choice of physician, care facility and frequency of interaction with the health system. The frequency of these decisions is important because when we – or our providers – make poor decisions, our chances for a long, healthy life are hurt.

The emerging field of behavioral economics is working to discover how people make decisions that can affect their health behaviors and health care, and how we can learn to guide people toward decisions that are in their best interest, even if they are hard, inconvenient or easy to forget. With this knowledge, policymakers and others can design environments, campaigns, messages and tools that make it easier for people to choose what is best for themselves, their families and their communities.

That’s why the Robert Wood Johnson Foundation’s Pioneer Portfolio has issued a call for proposals to identify promising experiments that apply the principles and methods of behavioral economics and choice theory to perplexing health and health care problems. By tapping into the behavioral economics community, we hope to uncover pioneering interventions and policies that will transform the way patients and providers make decisions that affect health for ourselves and our communities.

It is our hope that behavioral economists can help us learn how people think about their health and the decisions they make. Some research we fund will fail, but that’s okay–there will be critical lessons learned from these experiments. The successes and the failures will help to educate our work to transform health and health care for the better.

We’re seeking innovative ideas that apply the field’s principles and theories to perplexing health problems. We are particularly interested in supporting either experiments or secondary data analyses that test innovative solutions to the challenges of obesity and consumer engagement, but any problem can be addressed.

Do you have an idea of how behavioral economics can help change health and health care? Can you think of a health problem that can be transformed by learning more about how patients and providers make decisions about the care they give and receive? If you don’t plan to submit a proposal, leave a comment– I’d love to hear your pioneering ideas.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

Social Network Analysis, Obesity and Other Topics

Jul 31, 2007, 5:56 AM, Posted by Lori Melichar

I've been following with interest the reaction this week to the findings published in the New England Journal of Medicine on spread of obesity through social networks. While much of the discussion in the blogs and on the Web has been about the substance — whether obesity is, in fact, socially “contagious” (although the paper in fact hypothesizes that the spread of norms and perhaps behaviors may be the key) and has not always been accurate (the authors never, for example, suggest that discrimination against people who are overweight is either warranted or justified) — for my colleagues and myself at the Foundation, the chatter has been about the methods the researchers used to produce the findings through social network analysis.

It is not a new idea around here that social network connections are important to the spread of health and health care attitudes, behavior and status. Previous work funded by the Foundation and others suggests that understanding patterns and structures of social networks is as important to understanding health care systems and health behaviors as understanding the attributes of a given individual or care setting.

What is new to us is that researchers such as Nicholas Christakis, Robert Sampson, Peter Bearman, Thomas Valente and others are developing methods that transform a notion — that how a person behaves is dependent in large part on how that person is tied into a larger web of social connections — into an emerging science.

This science promises to improve our ability to 1) explore and understand the spread of health outcomes and behaviors — both good and bad — within complex, real-world social networks that evolve across time, 2) reveal new approaches to improve healthcare policy and practice.....and therefore to 3) inform the activities of those working to improve health and health care — including thousands of grantees RWJF has engaged in this work through out the U.S. (including, but not limited to those working to combat substance abuse, increase health care insurance coverage and meet other public health objectives).

Most immediately, we have funded* Nicholas Christakis and his colleagues at Harvard Medical School to continue their work building the science of social network analysis. By augmenting their current dataset, developing a new dataset, and continuing to innovate around the statistical methods necessary to produce rigorous findings, Christakis and colleagues will, we hope, produce new data and tools that can be used by other researchers interested in this area of intrigue to explore questions we haven't even conceived yet (and some we've been wrestling with for decades). My colleagues and I will continue to explore how the science of social network analysis can help us plan programs and evaluations of programs — particularly those that have as a purpose to improve the human capital of those working to improve the health and health care of Americans within our lifetime.


*sentence corrected August 10, 2007 to reflect the effective date of the grant.

This commentary originally appeared on the RWJF Pioneering Ideas blog.