Health Econ Week 6, 7, 8, 9, 10

Example of Nudging: Nudging Automatic Refills for Chronic Medications

"Opt-in" approach •Press 1 if you want to be transferred to Customer Care. •Press 2 if you are interested in enrolling in an automatic refill program. -15% signed up "Active choice" approach •Press 1 if you prefer to refill your own prescription by yourself each time •Press 2 if you prefer us to do it for you automatically. -32% signed up -In one study, researchers tested two approaches to enrolling people over the phone in a program that would automatically refill prescription medications for chronic disease. •In the first approach, people had to opt into the program. "Press 1 if..." "Press 2 if..." •In the second approach, the choice was framed to help people overcome their bias toward the status quo. "Press 1 if..." "Press 2 if..." This wording highlights the costs of not enrolling in the program, because the person will have to do the work him- or herself. -In either scenario, the program is the same, only the wording differs. -No one's choice was restricted.

Curative care for under 5

-62% receive private provider care.

What do quality comparisons tell us?

-Experience matches predictions from theory - i.e. private providers are generally: -More responsive to consumers (shorter waiting times, better hotel facilities, more time spent with healthworkers) -More likely to expend resources on unnecessary services and procedures (ex: C sections --> Moral uncertainty bc you don't know if there is a demand for C sections or if its because doctors get paid more for C sections -Clinical quality of private providers is incredibly variable - conclusions depend entirely on the specific provider types compared -If you can buy into private then it will be better but if you cant then your likelihood of care is better in a public facility

Facility delivery

-Facility delivery--> home deliveries attended by a skilled attendant -Still happens in 25% of the cases but really has gone down and will go down -40% of facility deliveries is done by private providers -Increasingly deliveries happen in hospitals and clinics and what those look like NOW really matters than how it looked 10 years ago

How can we get people to consume the socially optimal amount of vaccinations (QS)?

-For one you should lower the price to get the ideal quantity needed to get to the optimal demand for social benefit --> This will help people consume at the optimal quantity needed for social benefit. Mandates •Compulsory vaccination for school enrollment •Seatbelts •100% Condom Program in Thailand •Should there be more mandates?It's not always easy Price subsidies and incentives •Can overcome biased beliefs (lack of information), liquidity constraints, present bias, and intrahousehold conflicts •Taxes/subsidies can address externalities by trying to "internalize" the social costs/benefits (align incentives) •Increase consumption of goods with positive externalities •Decrease consumption of goods with negative externalities •Conditional cash transfers make the receipt of gov't transfers conditional on the adoption of a set of behaviors •Short-term subsidies may foster experimentation and learning about a product Peer effects Improving the supply

Principal-agent problems: Do providers get us to better health?

-Fundamental problem: information asymmetries. • Are providers good agent for patients? For employers? May not always work in patients best interest •In more competitive markets, providers may try to induce demand to compensate for lower market prices--> supplier-induced demand •Some providers can exploit monopoly power, resulting in higher prices and lower quantity of services rendered -Often little info about provider quality, few tools to find providers -Assumes providers are profit maximizers (self-interested) -Solutions: managed care, more info on quality, P4P

What is an intertemporal choice?

-Health-related decisions affect what happens to you in the future. Thus, all health-related decisions are intertemporal choices, which involve tradeoffs between their consequences now and their consequences in the future (i.e., over time -- intertemporally) •All health-related decisions have future consequences: •Use of antimalarial bed nets •Vaccinations •Seatbelts •Food choice •Preventive medical care •This can lead to trading off costs and benefits at different points in time. Preferences for intertemporal decisions are time preferences. •How people make these temporal trade-offs (i.e., how they discount future events) can affect decision making.

What is the behavioral economic model of human behavior?

-In contrast to the standard economic model, a behavioral economic model of human behavior incorporates all of the messiness of complex decision making. -We are more like Homer economicus than homo economicus, since Homer Simpson is so prone to making bad decisions. -There are lots of ways that we might not behave in our own best interest. -We may act impulsively and ignore the future costs of actions we take today--> When a person decides to drive while intoxicated, it is unlikely that he is considering the true potential costs of that decision. -We may misjudge which option is in our best interest/prefer the most--> Doing calculations in our head with all of the costs and benefits can be complex, and we often don't bother doing any real calculation at all. As a result, like Homer, we may decide to snack on a donut instead of an apple. -We use "rule of thumbs"/intuition to make decisions -We have limited ability to absorb and integrate information -We may not be able to consider all information about a decision, if we stopped to really consider all of the information related to every decision, we might never get anything done. -We may lack well-defined preferences if we're in a novel situation--> How should I know whether I should take a vacation in Paris or Istanbul if I've never visited either city? -All of these limitations - and others - mean that we may not behave as the rational choice model would predict.

Is information sufficient enough to achieve optimal health behavior?

-Information matters but no •There are gender differences in response to info--> Women may respond more to info due to greater value they place on health investments •Complementarities b/w education and info--> e.g., people may lack the education needed to assess the scientific soundness of diagnostic testing •Social learning •Cost of learning, e.g., if a drug is effective, may be high. •People may want to learn from observing others, but if everyone has this attitude there is an under-investment •Evidence from deworming, menstrual cups --> study the adoption of menstrual cups were given to girls & mothers. Having a greater number of friends who also received the product for free significantly increases the likelihood of self-reported adoption.

Can information provision promote tech adoption? Is it sufficient?

-It can help because if they have enough knowledge on the information they will be more or less likely to adopt certain behaviors if they know the negative health effects it can have but it's not the only way to promote adoption Health investments depend on: •Beliefs about how much prevention reduces risk of bad "shocks" •Beliefs about the type of sickness they face and the adequacy of accessible curative care Thus, HHs under- or overinvest if imperfect information Why is imperfect information more of an issue in LMICs? In LMICs, imperfect information is more prevalent b/c of low penetration of public health communication media, low education levels, and low access to health services.

Which model fits health and medical behavior: A standard or behavioral model?

-It depends -Just consider the choices many people make that affect their health. -Tobacco and other drug use -Having unprotected sex -Drinking and driving -Misdiagnosis and medical errors There are dozens of other examples in which our decisions lead to suboptimal health: which health plan to choose, whether or not to get a child vaccinated, which medication to prescribe. The rational choice model breaks down very quickly.

What does it mean if we say that we are underinvesting in a health technology? Give examples

-Malaria nets--> We know this work but some countries are not investing in these/ using them because there are barriers to adoption

What are barriers to technology adoption?

-No efficient technology for saving money -Households have limited ability to save money --> can take a loan to pay for a bed net but sometimes banks are not willing to loan money or there isnt a safe place to keep the money especially in LMIC--> All of these financial contraints may lead to an inability to save -In LMICs, financial markets are likely to be underdeveloped, with the majority of HHs lacking access to credit/banking services. -Health shocks may curtail ability to save, perhaps creating a poverty trap. -Risk of theft or pressure to share cash with friends or family. -This creates disincentives to save -Safe box: locked box made out of metal with padlock and key. -Lockbox: locked box but no key to the padlock. Respondents had to call program officer once they reached a saving goal. -Health pot: a side pot that members could contribute to at each meeting, earmarked for health, in addition to the regular ROSCA pot. -Health savings account: individual account earmarked for health •Overall, they estimate that 66% of the individuals in their study sample would invest more in health if they had access to a better saving technology.

What is nudging?

-Nudging is an attempt to change how choices are presented to alter people's behavior without forbidding any options & changing economic incentives.--> Directing people towards the right decision -It re-engineers the way choices are presented to provide a benefit to people who are prone to making decision errors. -However, they do so without imposing much harm on people who reliably make good decisions, because these rational people remain free to choose whatever option they want. -Nudges have an asymmetry to the effects they have. They have a big effect on some people by not others. -As a result, the philosophy behind nudging is often referred to as asymmetric paternalism. Another name for this philosophy is libertarian paternalism, because it combines libertarian respect of freedom of choice-with a-paternalistic promotion of social good •Changes how choices are presented to alter behavior without forbidding any options or significantly changing economic incentives •"Asymmetric paternalism" / "libertarian paternalism" •Benefits those prone to decision errors •Imposes little or no harm on those who reliably make decisions in their best interest

When should government intervene?

-One reason is that the models have different implications for when it might be appropriate for someone to intervene on someone's behavior. Reasons to intervene depending on model: Standard economic model -Redistribute wealth -Provide information -Correct market failures -Correct externalities—costs imposed on others -First, to redistribute resources to one group or another, typically using taxes or subsidies. Second, to educate people in order to help them form accurate preferences and beliefs. For example, calorie labels and warning labels on packages try to give information to consumers. Third, some decisions have spillover effects on other members of society. For example, not getting vaccinated or driving while intoxicated can endanger others. The government has a role to regulate behaviors that could cause these externalities—that is, external costs that one person's decisions impose on others. Behavioral economic model •Correct "internalities"—costs you impose on yourself •Provide "nudges" -•First, our bad decisions may impose costs on ourselves. These are called internalities, as opposed to externalities. If intervening can help me to make a better decision according to my own preferences, then there's a strong justification for doing so. Ex: I want to take my prescription medications, but I forget. There might be a role for health care programs to send me reminders to take my meds on time. •A second, related rationale introduced by behavioral economics involves "nudging."

How many OECD systems use the approved model for developing countries? Model: public, salaried, no choice of provider; no fees to patients

-Portugal, Spain, and Iceland

How is health in low-income countries funded?

-Primarily by out-of-pocket payments

U.S. Health Care financing by source

-Public -State/local (medicaid, safety net)=16% -Public- Federal (medicare, medicaid, VA, military, IHS) =27% -Private-employers (copremiums)=21% -Private- families (co-premiums)=13% -Families (cost-sharing)=16%

Why is it so difficult to save for preventive health products?

-Safe box: locked box made out of metal with padlock and key. -Lockbox: locked box but no key to the padlock. Respondents had to call program officer once they reached a saving goal. -Health pot: a side pot that members could contribute to at each meeting, earmarked for health, in addition to the regular ROSCA pot. -Health savings account: individual account earmarked for health •They observe a very large demand for the device and show that those who got access to the device were able to invest more in preventative health products in the following 12 months than those in the control group. •The study also finds that some individuals face strong-enough claims on their savings that a simple safe box is not enough for them to invest in health as much as they would like. Such individuals benefit from saving devices that enable them to earmark their savings for personal health investments. •Overall, they estimate that 66% of the individuals in their study sample would invest more in health if they had access to a better saving technology.

Socialized health care

-Socialized medicine is a health care system in which the gov't owns and operates health care facilities and employs the health care professionals, thus also paying for all health care services -This is a luxury good -More is spent on it relative to wealth as countries become richer -Governments are weak in LMIC so involving regulatory systems is a lot weaker in LMIC •If there is poor info and poor capacity to make regulatory decisions what do you do? --> Issue because as countries get richer, govt spend more on health care -Private healthcare spending is unrelated to national wealth

What is the standard neoclassical model/ rational choice model?

-The standard neoclassical model of economics assumes that individuals make rational decisions. As a result, this is also called the rational choice model. This "rational" person is sometimes referred to as homo economicus Homo economicus •People have well-defined preferences (or goals) and make decisions based on those preferences --> you might prefer the steak over the fish or other options •Doing so maximizes a person's utility (or welfare) •Preferences accurately reflect the true long-term costs and benefits of all available options •In situations that involve uncertainty, people hold accurate beliefs about what will happen and update their beliefs based on new information

So what does care-seeking actually look like?

-These interactions also create market interactions which provides opportunity for collaboration, competition -There is also no referral because it's non-formal and high cost because there are barriers to entry

The Demand Model

-This is much more complicated -If we generate an idea of where this demand curve is going to go towards if economic growth will be robust or weak, we will be seeing little demand increase Definition: Demand = f(income, cost of services, health status) ln(physicians per 1000it) = - β0 + β1*ln(GDP per capitait-1) + β2*ln(GDP per capitait-4) + β3*ln(GDP per capitait-5) +β4*ln(Out of pocket health expenditures per capitait-2) + β5*ln(Pop65it-3) + Country fixed effectsi + ξit • Estimated via a generalized linear model for 165 countries, 1995-2013 • Multiplied estimated coefficients from the regression model to future values of each predictor variable to compute the future predicted physician density. • Systematic ratios were applied to predicted physician densities to estimate the number of nurses/midwives (≈2 in 2013) and all other health workers (≈1.3 in 2013).

What is most health policy and planned based on?

-This model (picture) -Go to health center, then referral hospital, then specialist

What does a typical village look like and what do we know about most people in that village?

-Typical village is spread out and most people do not look for care within the village -The Health Centre isn't always in the middle and good distance for everyone in the village

What are the options?

-Very limited evidence of any kind on improving regulation such as statutory controls and self regulation by professional organizations -Considerable activity training, marketing, franchising, accreditation, vouchers and contracting, but until recently little robust evidence on clinical quality, coverage, equity, and cost-effectiveness

WHO and EMRO

-WHO has a big push led my EMRO to regulate purchasing from private sector •Gov't remains unprepared to regulate private sector so without that the chances that there will be proper care quality and coverage, UHC isn't feasible •Need to get better data by looking at unorthodox sources of care --> Sales data exists from pharmacy companies •Financing --> bc of electronic transfers its easier to pay for delivery --> much better ways to pay for care

What is a shortage of health workers?

-Wages: prices being paid to healthcare workers. Often times wages don't fully adjust to an equilibrium level so we will underpay healthcare workers which leads to a demand based shortage

What is the private sector?

-We are talking about the service providers -Ex: Drug retailers, private hospitals, diagnostic labs (what he will focus on)

Curative care for under 5 by wealth quintile

-Wealthy buy out of public services --> not universal truth but can see this hierarchy in a lot of countries -IF you are poor and have a cough, you go to a vendor and get medicine. -IF you are wealthy have a cough you go to see a provider Judgement call on if private is good or bad is difficult to tell --> There are methodoligcal challenges and it's hard to find matching public and private services -Few studies are direct comparisons and those that generally don't control for patient mix or health worker mix, and almost never for resource levels

Estimating need (old benchmarks vs SDG)

-What types of indicators would we need to for their to have decent health care services available? -Indicators: Antenatal care, ART, Cataract, Diabetes, Immunization, Family planning, Hypertension, Sanitation, SBA, Tobacco smoking, Tb=12 SDG Indicators -Took all indicators to see what burden of disease was and plotted a bunch of different countries and see what share of the SDGs was achieved in each country relative to health care workers in the population--> Country gets 1 point if HW density meets/exceeds the coverage --> Then you sum points weighted by burden of disease for each related condition -How many health care workers do they have per thousand and came up with 4.45 per 1000 is what you need to achieve the SDGs--> This is there population need and multiply that by 1000 -Need is greatest in low income --> most in Africa

Planning for the future

1) Need based: Planning for what the country will need to deliver priority health services • Based on future burden of disease, efficiency of service delivery, epidemiology 2) Labor market demand: Planning for what the country can afford in future• Demand = f(income or health spending, cost of services, demographics) Then adjust for supply: Planning for how many workers might already be available given current training, recruitment, and retention. • Assume nothing changes and things continue on their same trajectory as before

DellaVigna's categories of BE concepts

1.Non-standard preferences: time, risk, and social preferences deviate from standard neoclassical model--> Recall from Part 1 that we are assumed to make choices in line with our preferences. However, sometimes people have preferences that don't necessarily work in their best interest. For example, we might prefer a health insurance plan that covers small expenditures that we'd be better off paying out of pocket. Or we might prefer to donate to charity, even though we receive no direct benefit. 2.Non-standard beliefs: beliefs and expectations deviate from standard model--> •non-standard beliefs about their own abilities, about how they expect they will behave under certain circumstances in the future, or about how the laws of statistics or the laws of physics work. For example, people often believe they have a low risk of health conditions, such as HIV infection or lung cancer. Or young smokers under-estimate their likelihood of becoming hooked. 3.Non-standard decision making: decisions are made based on mental shortcuts, how the choice is presented, others' actions, imperfect attention/memory, one's emotions, etc.--> •For example, a doctor may diagnose a patient based on the health conditions she observed in other recent patients. Or people tend to re-enroll in the same health insurance plan each year by default, without considering changes in health care needs or changes to the health benefits package. (Non-standard is not the same as irrational)--> •People often use "non-standard" as shorthand for irrational behavior. The two are often synonymous, but that isn't always the case. For example, I might selectively pay attention to what's happening around me, because otherwise I'd never have time to accomplish anything in life. This selective attention could be perfectly rational but non-standard •In deciding when to intervene, it's important to distinguish between irrationality vs. making a well-considered deviation from what the rational choice model would predict.

Example 2 on Antibiotic Resistance

1.Problem. Antibiotic resistance threatens public health 2.Target behavior. Prescribing too much antibiotics 3.Inefficiency. Are people making a mistake? Yes because more people become susceptible to antibiotic resistance and doctors want to provide appropriate care to patients 4.Barriers.--> One cognitive barrier is that doctors may feel social pressure from patients to prescribe antibiotics when not needed. Another reason might be that doctors make mistakes due to work fatigue. Also People aren't aware of effect of antibiotics and there is pressure from the patients who push too hard for antibiotics which leads to misdiagnoses 5.Potential solutions. --> -public reporting of antibiotic prescribing rates to fellow MDs or to patients -asking doctors to sign an agreement to prescribe antibiotics appropriately, and then to put the agreement on a poster, perhaps along with a picture of the physician. setting up a pop-up alert in the electronic medical record system to flag inappropriate prescribing.

What are the steps to approaching a health problem like a behavioral economist?

1.Problem. Define the problem in behavioral terms.--> What behavior change is needed to achieve the health outcome of interest? Think about the individual, group, or population involved. 2.Target behavior. Select the target behavior contributing to the problem.--> These are the target behaviors you want intervene on. The more specific you are in specifying target behaviors, the easier it will be to find a way to intervene. 3.Inefficiency. Is target behavior making people/society worse off? --> is someone making an error or doing something less than ideal from the perspective of the person or society? 4.Barriers. Are cognitive barriers at play? Which ones?--> Consider the enablers and barriers to good behavior, with emphasis on the psychological drivers 5.Potential solutions. Develop/test potential solutions to address barriers. 6.Iterate. Repeat Steps 2-5 until problem is "solved."-> It's an iterative process!

Example of Obesity

1.Problem. People around the world have high rates of obesity. •Behaviors: Physical activity, caloric intake 2.Target behavior. Consuming too much junk food. 3.Inefficiency. Yes, many people want to lose weight but struggle. 4.Barriers. Junk food is tempting. Companies heavily market junk food. 5.Potential solutions. •Tax junk food, or subsidize fruits and vegetables. •Move healthy food to the front of the buffet table in school cafeterias. •Post weight loss goal and progress on Facebook.

What are the Major US Health reform efforts and events?

1940: Medican Benefits to increase compensation during WWII salary freeze --> offered employer based health insurance because of the salary freeze 1944: Franklin Roosevelt endorsed Wagner-Murray which provided for a national medical care and hospitalization fund. After FDRs death, Harry S Truman continued support of a national health care program but defeated by lobbying by the American Medical Association and outbreak of the Korean War 1965: Medicare and Medicaid established by LBJ 1974: Nixon introduced Comprehesive Health Insurance Act which would have mandated insurance through employers and federal Medicare for all. Ted Kennedy rejected it but later regretted doing so 1985: COBRA act enacted under Ronald Reagan amended the Employment Retirement Security Act of '74 to enable some employees to keep health insurance after leaving jobs 1993: Clinton Health Care plan was not enacted into law 1996: HIPAA enacted --> made it easier for workers to keep health insurance when they lost or changed jobs. Made use of national data for protecting, reporting, and tracking personal health info 2003: Medicare prescription drug improvement and modernization act established by George W Bush which included a prescription drug plan for elderly and disabled Americans 2009: re-authroization of state childrens health insurance program by Obama extended coverage to millions of children. American Recovery and Reinvestment Act included funding for computerized medical records and preventive services 2010: Health Carw Reform Act enacted by Obama extending affordable insurance to 32 million more Americans by extending Medicaid, insurance through employers etc.. 2017: ACA Dilution - failed ACA repeal, partial dismantling, no individual mandate, "noncompliant" plans, subsidy cuts, But more medicaid expansion

Nurse Absenteeism 2008 study --> RCT design: tie compensation and employment to attendance

2 interventions: • Single ANM monitoring: Main assistant nurse/midwife (ANM) required to show up every Monday • Centers with additional ANM: Additional ANM required to show up 3 days/week Punishment: • absent >50% for 1 month-->pay reduced by degree of absence •absent >50% for 2+ months--> suspended Graphs: -ANMs took longer to report broken time stamp machines -Supervisors were complicit in allowing more exempt days and not punishing absences -No incentive to be monitored -No enforcement means that things will revert back to the way they were

Explain the H2O quality info study

3 pieces of information provided to HHs in a Dhaka suburb 1.Results of well tests for arsenic contamination 2.Health consequences of drinking water with unsafe levels of arsenic 3.Results of a health exam-->included urine and blood sample and told respondent if they had symptoms of an arsenic-related illness •60% of HHs informed that they were using unsafe wells changed wells. •Only 8% of HHs in control areas changed wells in same time period. -Found an increased probability of changing to a different well in response to arsenic in well at baseline -Knowing that the household's well water has an unsafe concentration of arsenic increases time spent walking for water 15-fold.

Often times we don't get HW*, why do we see this shortage?

A lot of failures such as it's expensive to go to medical school or there are other fields that provide more money that can lead to a shortage. We often have set tier wages for what they are willing to pay. There is very little wiggle room for how that individual can be compensated There are a lot of regulations of work hours. Must manage staff turnover to ensure the correct ratio Trade unions and licensing--> who can supply their labor in this market? There are barriers to entry to allow supply into this market--> you don't want poorly qualified people delivering health care but this could also reduce the supply of these health care workers B = # demanded A =# willing to work Demand based shortage--> # of workers demanded exceeds the # supplied (B-A)

Explain Barrier 3

Barrier 3: Financial constraints Why would HHs not be able to save? -Health investments depend on HH's access to financial markets: •If HH lacks access to credit, reduced resources to spend •If they lack access to safe way to save, they face a negative interest rate -In LMICs, financial markets are likely to be underdeveloped, with the majority of HHs lacking access to credit/banking services. -Health shocks may curtail ability to save, perhaps creating a poverty trap. -Risk of theft or pressure to share cash with friends or family. This creates disincentives to save Study: -141 villages-->Purchase unsubsidized or on one-year credit at 20% interest -Only 2% of households purchased a bed net in cash, whereas 52% purchased at least one net on credit--> Borrow money for bed net vs. just paying cash -Loans may help increasing demand. •However, not everyone will buy, reducing benefits of externalities •Do not address low usage rates -Loans can help sustainability but at expense of effectiveness

Explain Barrier 4

Barrier 4: Psychological constraints •Ex: Time preferences (how make tradeoffs over time) •Individuals may not discount the future at a constant rate: many display a "bias" toward the present (present-biased preferences). •Returns to preventive health investments far in the future --> procrastination in adoption of preventive health behavior •Procrastination less likely for curative health investments (after bad health shock) b/c they matter for current utility.

What are some barriers to adoption?

Demand-side barriers •Information and knowledge •Intrahousehold conflicts and nonmonetary costs •Financial constraints and cost •Psychological constraints such as time preferences Supply-side barriers •High, unreliable absenteeism •Low quality

Static Model of labor market

Demand: Providers are employed by public and private sector organizations deliver services that consumers pay for Supply: The number of HWs that are available and willing to be employed in service delivery given prevailing wages Equilibrium: An employer will hire workers HW*, the point where demand = W* -As you add more providers than their wage goes down -As wages rise, workers will either come into market or existing people in market could opt to work longer hours HW= market wage and # of health care workers that can be employed at that wage --> What they are willing to hire at that wage W= that is the wage that will attract health care workers (what they are willing to pay and what health care workers are willing to accept)

Explain Barrier 1

Health investments depend on: •Beliefs about how much prevention reduces risk of bad "shocks" •Beliefs about the type of sickness they face and the adequacy of accessible curative care Thus, HHs under- or overinvest if imperfect information Why is imperfect information more of an issue in LMICs? In LMICs, imperfect information is more prevalent b/c of low penetration of public health communication media, low education levels, and low access to health services.

Is there low adoption of key health technologies?

Households in low-income countries tend to invest relatively little in preventive health care. Both malaria and diarrhea can be prevented. •Consider malaria and diarrhea that account for roughly 18% and 16% of under-5 mortality in sub-Saharan Africa •Insecticide-treated nets reduce malaria incidence 50% and mortality 20% •Point-of-use water chlorination reduces diarrhea by 37% •Both technologies are used by < 10% in sub-Saharan Africa

How does HRH (human resources for health) lead to global health impact?

Input: -Training -Compenstion -Technical efficiency -Controlling quantity goes into outputs.. Impoved... -HRH density -HRH distribution -HRH performance -HRH productivity which goes into outcomes.. Improved... • Service coverage • Service delivery • Quality of care which goes into impact.. Reduced... • Mortality • Disease incidence/ prevalence

How do intrahousehold conflicts affect preventive health investment?

Intrahousehold decisions •Differences in preferences with children and parents •Power and bargaining with father and mother if the man yields more $$ -Different decisions within households on whether or not we should invest If male head of house controls income he may make decisions on how the money is spent and whether to invest in a bednet which leads to an underinvestment relative to what other people might want to invest There are differentials in power that can lead to these different preferences

Explain Barrier 2

Intrahousehold decisions •Differences in preferences with children and parents •Power and bargaining with father and mother if the man yields more $$ Nonmonetary costs •Time costs--> cost of time to getting to a store to buy bed nets •Convenience •Hassle costs (e.g., paperwork) •Cultural barriers Ashraf study: •Women in Zambia offered voucher for free modern contraceptive, including injectables that are concealable •Condition 1: voucher provided to women alone and required her signature only •Condition 2: voucher provided in presence of husband and required both of their signatures Couple treatment: •19% less likely to visit a family planning nurse to redeem voucher •25% less likely to use concealable contraception •27% more likely to give birth in next year •Bigger effect for women who doesn't want a kid but thinks her husband does--> believe that husband wants a kid

How do we reach Universal Health Coverage?

Lancet Commission on Investing in Health: • "Grand convergence": Maternal and child survival in low- and middle- income countries could equal those found in upper middle-income countries within a generation. • The way forward is to achieve UHC. • Need to prioritize access to essential, quality health services, with financial protection for the poor •Having enough health workers is essential to ensuring access

Needs Based vs. Demand-Based Shortages

Low income: There is a need based shortage --> no strong infrastructure for the demand--> unlikely to reach SDG goals Lower-Middle Income: Upper Middle Income: High Income:

What policies can address barriers to technology adoption?

Mandates •Compulsory vaccination for school enrollment •Seatbelts Price subsidies and incentives Peer effects Improving the supply

What are some policy implications for these barriers?

Mandates •Compulsory vaccination for school enrollment •Seatbelts •100% Condom Program in Thailand •Should there be more mandates?It's not always easy Price subsidies and incentives •Can overcome biased beliefs (lack of information), liquidity constraints, present bias, and intrahousehold conflicts •Taxes/subsidies can address externalities by trying to "internalize" the social costs/benefits (align incentives) •Increase consumption of goods with positive externalities •Decrease consumption of goods with negative externalities •Conditional cash transfers make the receipt of gov't transfers conditional on the adoption of a set of behaviors •Short-term subsidies may foster experimentation and learning about a product Peer effects Improving the supply

What is the organization of the Health System in the US?

Medicare: Federal program for adults 65 and older and some people with disabilities--> public financing, but still private care providers that are giving these --> not socialized insurance. It's a private system with public financing Medicaid: (public financing) joint federal-state program for certain low-income populations; called Medi-Cal in CA Employers: (private financing) traditional way private health insurance purchased, regulated mostly by states Marketplaces: (private financing) a.k.a. health insurance exchanges, administered by states or feds, established under 2010 ACA, with income-based premium subsidies for low- and middle-income people

Is private healthcare spending related to national wealth?

NP

Need-based vs. demand-based shortages projections

Need based shortage Shortage=Need-Supply -Need is the number of His required to deliver a certain X services to Y people --> depends on size of population in need --> NEED IS PRICE INDEPENDENT and is based on DEMOGRAPHICS/HEALTH STATUS of population -At a lower wage, our need will be beigger than demand and looking at quanitity need vs quantity supplied it leads to a larger needs based shortage -Need is the % of population that has access to skilled health workers 1) Need based: Planning for what the country will need to deliver priority health services • Based on future burden of disease, efficiency of service delivery, epidemiology Demand based shortage Shortage=Demand-Supply -A is number of workers supplied and B is number demanded -Demand is a function of income, cost of services, and health status 2) Labor market demand: Planning for what the country can afford in future• Demand = f(income or health spending, cost of services, demographics) Then adjust for supply: Planning for how many workers might already be available given current training, recruitment, and retention. • Assume nothing changes and things continue on their same trajectory as before

Static model of labor market + need

Need: The number of HWs required to deliver a certain X services to Y people • normative perspective - what services do people need? • also depends on size of population in need • also called the epidemiological model Q: What's C-B? Need>Demand C-B is the policy conundrum: You need C amount of workers but only have B--> How can we mobilize additional resources to employ more workers or make our health care system more effective? It's what we must come up with.

Sampling of BE concepts--> What are some of the types of behavioral economic concepts, organized into the 3 categories?

Non-Standard Preferences •Present bias •Reference-dependentrisk preferences (prospect theory) •Social preferences for fairness, reciprocity, altruism Non-Standard Beliefs •Overoptimism •Projection bias •Over-emphasis on lessons from small samples Non-Standard Decision Making •Default effects •Heuristics & menu effects •Limited attention & memory •Framing effects •Emotions •Persuasion & social pressure

Nurse Absenteeism 2008 study (looking at provider problem)

Observation: Government facilities are pretty close and less expensive, and staffed by trained personnel, so why do people go to more expensive private providers with uncertain qualifications? •Hypothesis:People don't go because nurses aren't actually there •Q:Why might this behavior be optimal for nurses? It's optimal behavior cuz the nurses are getting the money without doing the work •Solution: institute set of rewards and punishments tied to attendance -Note: Doesn't mean that if they show up, there will be quality services delivered -Would this be enough to get people to go to gov't facility?

What are the factors accounting for growth in personal health care expenditures?

Personal health care expenditures (PHC) measures the total amount spent to treat people with specific medical conditions. It represents about 85 percent of total national health expenditures over the projection period. Average annual personal health care spending growth is decomposed to demonstrate the relative contributions of underlying price growth (economywide and relative personal health care price inflation), use and intensity of medical services, population growth, and age-sex mix. -During 2018-27 personal health care spending growth is expected to average 5.5 percent, with growth in personal health care prices expected to account for nearly half of that growth, on average. Growth in use and intensity is expected to account for just under one-third of the average annual personal health care spending growth, with population growth and the changing age-sex mix of the population accounting for the remainder.

Estimating future need: SDG Benchmark Approach

Q: How many health workers will be need to achieve SDG goals by 2030? SDG Composite Index Score: • Uses 12 SDG Indicators • Country gets 1point if HW density meets/exceeds the threshold for coverage > 80% (max 12 points) • Sum points, weighted by burden of disease for each related condition

What are the strengths and weakness of Fee for Service?

Strengths •Encourages productivity: do more to get paid more •Encourages technology adoption •Encourages treatment of severely ill •If more care is needed, more revenues are earned •Administrative simplicity? Weaknesses •Does not support coordination across caregivers •Does not support coordination across episodes •Favors surgical over medical intervention? •Supports "over-treatment" in instances of uncertainty (e.g., at end of life)? •Some third party (insurer or gov't) must counter incentives for over-treatment -Traditional fee-for-service reimbursement creates financial incentives for performing more tests, procedures, etc., regardless of whether additional care benefits patients. -Fee-for-service reimbursement also contributes to poor coordination of care because providers do not have an incentive to work with one another to maximize patients' health and functional status, and there is no funding dedicated to support others who might align and coordinate care.

What are the strengths and weakness of capitation?

Strengths •Supports coordination of services and caregivers •Supports efficient use of resources •Reduces need for third party oversight •Physicians rather than insurers decide what is appropriate care Weaknesses •Encourages "under-treatment" in cases of uncertainty (e.g., unproven technologies) •Encourages risk-avoidance ("cherry picking") •Requires sophisticated physician capabilities for financial management •Requires large scale of physician organization to spread risk of unexpected high-cost patients -Under capitation, physicians are paid a fixed amount, usually on a per patient per month basis, for a defined set of health care services. -This set of services may include specialty care and screening and diagnostic tests in addition to primary care services. -This payment method encourages physicians to provide care as efficiently as possible because they are paid the same amount regardless of the cost of providing care to patients. -Capitation also encourages physicians to focus on prevention of illness and management of chronic disease. However, there is concern than primary care physicians subject to capitation may withhold access to expensive services that their patients need, such as imaging and specialist consults, to maximize their incomes. -In addition, patients' needs for primary care vary substantially. Unless capitation rates are adjusted to reflect differences in age, gender, and disease burden, capitation payments may not be sufficient for primary care physicians to effectively manage patients with complex needs.

Conceptual frameowkr for projecting health workers

Strong labor market demand (shortage): Might result in future shortage because # demanded is larger than our supply Need: Determined by population (bigger populations need more workers) Supply: Weak labor market demand (surplus): i.e subsaharan africa: Some countries have weak economic growth and cant afford health workers so we have a supply of workers higher than our demand but no one can employ them cuz economy cant support it

Pinto's Categories of BE concepts

There are several ways to group different concepts in BE. One typology comes from your reading by Pinto et al. It includes 3 categories: 1)Bounded rationality: Systematic errors when using the automatic system in selecting optimal behavior--> represents the errors we make when we rely on our brain's automatic processing system, as opposed to its more deliberative system. This might include use of heuristics, or rules of thumb, and limited ability to attend to information in our environment. 2)Bounded willpower: Inability to follow through on optimal behavior--> an inability to follow through on a goal at the time of acting. This happens when people have self-control problems or decision fatigue. 3)Bounded selfishness: Decisions are affected by what others do or think--> includes situations in which a decision is influenced by what others do or think, as occurs due to the influence of social norms or peer effects.

Plot Health worker density and proportion of SDG indicators achieved

This is a goal: If every country reaches 4.5 health care workers by 2030 they will achieve the SDG goals

What are the trends in national health spending as a share of GDP in the US?

Total health spending represents the amount spent on health care and health-related activities (such as administration of insurance, health research, and public health), including expenditures from both public and private funds. Health spending refers to national health expenditures. Projections are shown as P and are based on current law. The 2017 figure reflects a 4.2% increase in gross domestic product (GDP) and a 3.9% increase in national health spending over the prior year. As a wealthy country can we afford to continue to keep spending money on health care -some people say it's a good use of resources but others say we are sacrificing other things

Life expectancy vs. health spending per capita

US is an outlier vs. OECD countries •Much higher spending per capita •Much worse life expectancy Healthcare is one of the most important inputs to produce health; and life expectancy is one of the key measures of a population's health. -The visualization shows the relationship between life expectancy at birth and healthcare expenditure per capita. -As it can be seen, countries with higher expenditure on healthcare per person tend to have a higher life expectancy. -And looking at the change over time, we see that as countries spend more money on health, life expectancy of the population increases.... -The US is an outlier that achieves only a comparatively short life expectancy considering the fact that the country has by far the highest health expenditure of any country in the world." Note: the association b/w health spending and life expectancy also holds for LMICs:

OECD/LMIC

• Private for OTC drugs for both LMIC and OECD • Private for pharmacies for both LMIC (98%) and OECD (100%) -Primary care--> LMIC is 40-85% private and 77% in OECD is private -Specialist is 95% private in LMIC and80% private in OECD

What are commitment contracts?

•A voluntary, binding contract that precommits a person to follow through on a plan -A person commits to paying a penalty for failing to reach a specified goal. The idea is that a person will voluntarily enter into the agreement in order to bind himself to follow through on a plan •A common approach is a deposit contract •Uses "loss aversion," a preference to avoid losses over getting gains--> In a deposit contract, a person deposits his own money into an account, which he agrees to forfeit for failing to achieve a certain goal. This can be especially motivating because it takes advantage of the fact that people generally prefer to avoid a loss rather than get an equal-sized gain. •Applications •Preventive health savings accounts •Physical activity and weight loss •Smoking cessation •Insecticide-treated bed nets

What are the administrative costs as a share of total health expenditures?

•Administrative costs of administering public and private insurance have risen over time. •So have providers' administrative costs (e.g., billing departments) -Administrative expenses include the cost of administering private insurance plans and public coverage programs but not the administrative costs of health providers

What is behavioral economics?

•Behavioral economics (BE) incorporates ideas from psychology into economic models to develop new hypotheses and interventions. •BE focuses on: •Behavior in real-world settings, not the lab •Barriers people face and mistakes they make while trying to make complex decisions. •These cognitive barriers, a.k.a. behavioral biases or decision errors, hurt the individual-and often society as a whole. •Behavioral biases: systematic deviations from rational behavior.

How might subsidies and incentives overcome these barriers?

•Can overcome biased beliefs (lack of information), liquidity constraints, present bias, and intrahousehold conflicts •Taxes/subsidies can address externalities by trying to "internalize" the social costs/benefits (align incentives) •Increase consumption of goods with positive externalities •Decrease consumption of goods with negative externalities •Conditional cash transfers make the receipt of gov't transfers conditional on the adoption of a set of behaviors •Short-term subsidies may foster experimentation and learning about a product

Examples of underused technologies

•Deworming •Iron supplementation •Oral rehydration therapy--> does not stop the diarrhea but prevents dehydration. •Immunizations

What are some explanations for underinvesting in prevention?

•Ex ante moral hazard: behavior changes that occur before an insured event happens and make that event more likely •Externalities: Actions of one person (or producer) affect the utility of another person •Private benefits or costs diverge from social (external) benefits or costs. •Markets tend to under-produce these goods --> one type of market failure •Ex. of negative externalities: infectious disease risk, pollution, valuing other people's access to or use of health care •Ex. of positive externalities: vaccination, deworming •Public goods have 2 characteristics: 1.Non-excludable: Costly or impossible for one user to exclude others from using the good 2.Non-rivalrous: when one person uses a good, it does not prevent others from using it •Public goods typically generate a positive externality--> Ex: smoke-free air, no risk of infectious disease, new intellectual property, access to nutritious food/parks •Many aspects of health services are "quasi-public goods" (partial excludability or partial rivalry) •Problem: Little incentive to preserve or produce public goods under normal market incentives. •"Tragedy of the commons" or free-rider problem--> groups of people are responsible for the management of a resource for which none of them holds exclusive rights •People are either unaware of the effect of their activity on the long-run quality of the resource (myopic behavior) or are in a race to capture the benefits provided by the resource. •Examples: drug resistance, MRI scans, expensive diagnostics

What is the episode of care (bundled) payment and what are it's strengths and weaknesses?

•FFS isolates each component of the process of care, undermining incentives for coordination, while capitation places epidemiological risk on physicians •Episode-of-care payment sets one fee for a bundle of services related to a single course of care •Must define beginning and end of episode •Must decide which services during that period belong to this episode and which are unrelated •Must adjust for severity of illness (need for services) •Must not adjust for complications (not same as severity) Under bundled payment, a single payment is made for all services associated with a discrete episode of illness, such as a knee replacement or perinatal care. Pros Like capitation, bundled payment creates incentives for physicians to provide care as efficiently as possible, including improving coordination of care among physicians, hospitals, and other entities involved in a patient's care, such as home health agencies. Cons -Physicians, hospitals, and other organizations paid via bundled payment are only at financial risk for medical services included in the bundle. -Implementation of bundled payment can be difficult because the medical services included in the bundle need to be defined and the payments need to be divided up among participating physicians (and potentially hospitals). -Surgeons are often paid on an episode basis for care pre, post, and during procedure

What are forms of physician payments?

•Fee for service: one fee for each service provided •Capitation: fixed payment per patient (typically per month) •Salary:No matter what you are providing (Kaiser) you get this salary) •Episode-of-care: one fee for a bundle of services related to a single course of care ("bundled payments")-->For one surgical procedure, after care, bed care is all 1 episode--> they will be responsible for everything that happens in that bundle of services •Pay for performance: bonus or penalty based on quality measures--> based on health status of patient Organization and payment •Payment to the physician group •Payment to the individual physician -Physician payments are one key category of supply-side incentives, hospital payments being the other. -One of the biggest challenges in health care is designing payment systems that create financial incentives for physicians and other health professionals to deliver high value care. -Diagnostic Related Grouping (DRG) payments are bundled payments to hospitals (e.g., paid by Medicare). These are fixed payments determined by a patient's diagnosis.

What is the annual growth rate of GDP per capita and total national health spending per capita from 1970 to 2017?

•Health spending growth has slowed, and is now more on pace with economic growth -GDP has been growing over time but health expenses is growing over time much more. -GDP is growing because health care is growing at a faster rate. They are growing at the same rate

What is the billing and insurance-related (BIR) inefficiency?

•How big is $400 billion in annual billing-related waste? •>$1 billion per day •~$1400 per individual per year •All the health spending in California. -Large chunk is through private insurers and it comes to 400 billion that we are wasting -Argument for health reform: could reduce the inefficiencies if you have just 1 payer with set rates that there will be less scope for these inefficiencies

What is the average annual growth rate for select service types from 1970 to 2017?

•In recent years, spending on hospitals, physicians, and prescriptions has slowed to a similar pace -The rate of growth for medical services (e.g. physicians/clinic, hospitals) varied by service type until recent years. During the 1970s, growth in hospital expenditures outpaced other services, while prescriptions and physicians/clinics saw faster spending growth during the 1980s. Prescriptions continued their elevated growth during the 1990s as well. Between 2010 and 2017, average spending growth on prescription drugs grew and physicians/clinics was 4 and 4.4%, respectively. Spending grew at a similar pace for hospitals and clinics

What is the prospect theory?

•In the 1960s-70s, psychologists Daniel Kahneman & Amos Tversky launched the field of behavioral economics with their work on judgment and decision making, culminating in prospect theory. •Kahneman won the 2002 Nobel Prize in Economics for this work

What is the federal spending as % GDP from 2004 to 2049?

•Includes Medicare, Medicaid, CHIP, marketplace premium subsidies •Driven primarily by Medicare due to population aging -Medicare is net of premiums and other offsetting receipts -Within our federal budget which is from taxes, health care consumes a massive proportion -People don't like paying higher taxes especially if they don't think its leading to better health outcomes -It is expected to grow because of medicare --> aging population is growing, therefore you are paying into your medicare in your life -Medicare is financed through payroll taxes but it's not your personal medicare, just medicare as a whole -This shows what we are spending in the federal gov't (where is the money going out) -This focuses on where the money is going out

Universal Health coverage

•Innovations on how this happens --> Why this idea of understanding private health care markets is in resurgence? •Wasn't much data on understanding private health care--> couldn't do much about private sectors •There are ideas that there will be much more money and emphasis on expanding coverage --> however, a lot of government providers don't exist so the only option is to figure out how to work with private providers

What are some design suggestions for present bias?

•Make feedback relatively immediate •Set deadlines to prevent procrastination •Set smart default options •Precommit to a goal

What are the potential drivers of U.S. health spending?

•Medical price inflation •Increased cost of "input factors" such as provider salaries and medical supplies -Prices have been increasing over time. Prices are what is driving health care. We pay higher prices in drugs, doctors, nurses than in anywhere else in the world. •Hospital market structure and hospital charging practices •Increasing # of hospital mergers (less competition) •Hospital systems gaining market power to charge higher prices -Could be market structure: fewer and fewer hospitals have been having independent provider groups which means there is less competition (drives prices higher) --> must come to a deal about how much providers will be paid •Provider reimbursement •Including fee-for-service payment for physicians leading to "overuse" of services -Pay providers with fee-for-service = overuse of health services because there arnt enough controls in place in lab tests and drugs provided --> since it is subsidies, employers plans that they are offer are very generous because there is a built in subsidy--> creates a moral hazard which drives this spending •Employer sponsored health insurance •Tax deductible status of health insurance promoting overuse -Pre-tax dollars which means you are getting more for your money which leads to voeruse and is a distrotion about amt of healthcare that gets provided •Population growth, aging, chronic disease prevalence In general, the market has consolidated and experienced a decrease in competition. - The breadth of provider payment (mainly bundling) affects the degree of competition of providers. If payments are very narrow, the degree of competition can increase. - The generosity of payments changes the market structure through the effect that it has on entry decisions and the # of providers - hospitals or physicians - than can exist side by side on the market. -With larger payments, there can be more providers because, for the same cost structure, revenues are larger. The US population has aged - due in part to medical advancement. Older persons are expected to have more health problems and consume more health care than younger persons. Changes in disease prevalence such as increases in the level of obesity and diabetes may contribute to health spending.

Study Conclusions

•Nurses respond to financial incentives. Monitoring intervention was highly effective in the beginning. •But no lasting effect; requires political will and consistent enforcement. In fact, attendance was lower at the end of the study period than it has been historically. • No effect on patients seen--> Why? •Small positive spill over effect on unmonitored days.

What are the trends for per-capita out of pocket spending from 1970 to 2017?

•Per capita OOP costs have grown since 1970 ~30% of private insurance has a high deductible -In dollar terms, out-of-pocket expenditures have grown steadily since 1970, -Out-of-pocket medical costs are in addition to the amount individuals contribute towards health insurance premiums. -Although OOP costs per capita have also been rising, compared to previous decades, now makes up a smaller share of total health expenditures.

What is present bias and what are the 2 flavors of present bias?

•Present-biased preferences, or present bias is a desire to seek immediate gratification and avoid immediate discomfort •Informally, a "self-control problem" 2 flavors of present bias: 1) Consumption behaviors --> Consumption behaviors produce some benefit now but incur some cost in the future. Due to the immediate benefits, people tend to consume too much of these behaviors, relative to what would be ideal, and people often regret these behaviors after the fact. Examples might include smoking, eating junk food, and engaging in unprotected sex. Again, these all have a benefit now, but health and economic consequences in the future 2) Investment behaviors--> •These are costly to do now, but provide benefits in the future. Due to the immediate discomfort, people tend to do too little of these activities relative to how much they'd like to. Examples include doing physical activity, flossing, and preventive screening services like colonoscopies.

What is the annual change in price and quantity indexes of health services?

•Prices have historically driven health services spending growth •But use (utilization)is now the primary driver -Health services spending is generally a function of prices (e.g., the dollar amount charged for a hospital stay) and utilization (e.g., the number of hospital stays). -In recent years, utilization - likely driven by coverage gains under the Affordable Care Act - has been the dominant driver of health services spending.

Social loss in the market for flu vaccination

•QS: Socially optimal # of vaccinations •QP: Privately optimal # of vaccinations •Fewer people get vaccinated than is socially optimal, because many of the benefits are social, not private How can we get people to consume the socially optimal amount of vaccinations (QS)?

What is the U.S. health system performance compared to other OECD nations?

•Spending per capita ~60% higher •Generally fewer doctor visits and hospital days •Difference in spending due to: •Price (costs of doctor, procedure, drugs) •Use of high technology (Dartmouth Atlas: no benefit) •Administrative costs (later) •Weak cost controls •Drugs, outpatient (RBRVS), inpatient (DRG) •Fee for service, for expensive items supplants primary care--> Fee for service encourages more speciality and less primary care •Health care outcomes same or worse -Under FFS, it is imperative to have a method for setting the price (payment level) for each detailed visit, test, procedure. The RBRVS (Resource Based Relative Value Scale) is based on surveys of time and input costs. It does not seek to reflect the value (outcomes, convenience) of the services to the patients. -Medicare faces political pressures to increase the relative value of services where input costs rise but no pressure to reduce RVS where costs decline. -Primary care payments have declined as payments have increased for selected specialty services, esp. related to tests -Diagnostic Related Grouping (DRG) payments are fixed payments (administered prices) determined by a patient's diagnosis, paid to hospitals (e.g., by Medicare). DRG system codes all admissions into categories that ideally are homogenous with respect to costs.

Example: Night guy vs morning guy?

•This concept of Night Guy and Morning Guy is actually how behavioral economists think about certain preferences over time. There's Night Guy, your present self who is tempted by the world around you, and Morning Guy, your future self who wishes your present self would show some self-restraint. This can create conflict between your dual selves, and can lead people at times to have inconsistent preferences over time. •More importantly, Night Guy imposes a cost on Morning Guy. This is the essence of an internality, in which a person imposes a cost on him-/herself. -Recall from Module 1 that an important rationale for intervention is to correct internalities.

What are the relative contributors to total national health expenditures in 2017?

•Total health spending was ~$3.5 trillion in 2017 •Hospital & physician services are ½ of total health spending -Most of our money goes towards hospital care! -Hospital spending represented 33% of overall health spending in 2017, and physicians/clinics represent 20% of total spending. -Prescriptions accounted for 10% of total health spending in 2017, which is up from 7% of total spending in 1970. SPENDING CATEGORY DEFINITIONS Government administration includes the administrative costs of government health care programs such as Medicare and Medicaid. Investment includes noncommercial research, structures, and equipment. Net cost of health insurance reflects the difference between benefits and premiums for private insurance. Other health care refers to other health, residential, and personal care, including care delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities. Other medical products refers to durable medical equipment and nondurable medical products.

Summary of Behavioral Economics

•Whereas neoclassical economics assumes we are rational actors, behavioral economics focuses on the ways we are irrational. •The BE model provides new justifications for public and private intervention. •To design an intervention using BE insights: identify a target behavior, determine if it is an inefficiency, consider whether it cognitive barriers and which ones, find ways to overcome the psychological factors that contribute to the barriers.