March 8, 2008 
I mentioned it yesterday in the post about Drug Benefit News, and I think I have talked about it early last year. The question is how do people view price as influencing their decisions about drugs.
- Does free influence perception of value?
- Does paying 10% of a $100 drug sound better than paying 10% of a $30 drug?
USA Today had an article the other day on this topic. They talk about a study in which subjects were given sugar pills. They were all told that it was a new pain drug. Some were told that it costs $2.50 per pill and some were told that it costs $0.10 per pill. A series of shocks were then administered to the patients. 85% who were told that it cost more (versus 61%) said that they felt less pain after the pill. (The Placebo Effect)
“What we experience is partially reality and partially what we expect to experience,” says the senior letter author, Dan Ariely, a Duke University behavioral economist whose new book, Predictably Irrational, explores why people make the choices they do.
They go on to say that this might explain why some of the Cox-IIs (i.e., Vioxx, Celebrex) were so successful and could explain why people don’t think generics are working as well as the same brand drug they were taking. They also say this could convince people to be less compliant since they don’t see as much value in the generics. [There must be a study out there that shows compliance of generics versus brands.]
This should influence how you interact with patients and present information to them to convince them of value.
You can see some additional information from one of the study authors on his blog.
Enabling Healthy Decisions 
On the issue of predictable irrationality and perception, what about the situation where a group of people rate their health status much better than another group of people, but the first group generates nearly twice the level of medical claims as the poorer health status group. That’s counter to the current belief that health status drives claims. So, what’s going on?
Well, the difference is how each group of people judge when it is time to seek care. When do they say, it is time to go to the doctor? Type 2 people only go to the doctor when problems are serious. They ignore their health and are apathetic towards it. They have health problems, but they just live with them. Type 7 people go to the doctor at the first sign of a problem. They monitor their health and are very proactive about it. If something appears, they seek care for it. These are the types of people it seems the health industry wants to build more of to reduce costs.
In a 1995 study of Kaiser members in Hawaii, the Type 2 members rated their health status 11.9 (SF-12 scale) and Type 7 members rated their health status at 14.3. The Type 2 group had avg claims pmpy of $1,541; the Type 2 group had avg claims pmpy of $2,040. Whoops! The higher health status Type 7’s had nearly twice the claims as the lower health status Type 2.
Let’s bring things closer to present time. In 2004/2005 year long study of Cigna members in a DM program the same patterns were there. At the baseline, the Type 2 group reported avg health status of 3.26 (1 to 5 scale) and the Type 7 group reported avg health status of 3.45. Type 7 were higher again! Type 2 avg claims pmpy were $6,176. Type 7 avg claims pmpy were $9,910. Whoops again! After a year, the DM intervention did not change this. At the end of the study, Type 2 people reported health status at 3.3 (a touch better), and the Type 7 people reported health status at 3.54 (a touch better again). The Type 2 group’s claims went down to $4,750 pmpy. That’s over a $1,400 drop. The Type 7 groups claims after 1 year of DM intervention dropped to $9,017 pmpy (almost a $800 drop). The Type 7 higher health status group still had claims that were nearly twice the level of Type 2.
The moral to this story is that the predisposition to seek care is a huge driver of health care costs. In some groups of people it overrides their perception of their health. In the 1995 study and the 2004/2005 study, the reason why the Type 7 people had higher claims is because they came in demanding care. That’s all. And the doctors are happy to see them!
This all harkens back to an earlier blog where you discussed the Dutch study and how preventive care did not lower health care costs. Providers have convinced everybody that the cure to lower health care costs is to encourage more people to become like Type 7 and to make care more accessible and affordable.
Predictable irrationality?
Looks like it to me.