Scott MacStravic, PhD
The concept of arraying people and even entire countries on a “hedgehog vs. fox” continuum has been around for thousands of years, since originated by an ancient Greek philosopher. At the hedgehog end are those who look for and rely on “one big thing,” a universal and simple solution to problems--rolling up in a ball when attacked in the case of actual hedgehogs. In contrast, the fox end belongs to those who look for and rely on a large number of “little things,” complex and often independent, though potentially integrated solutions. No one knows how a fox will react when in danger, not even the fox.
The assortment of “solutions” proposed for healthcare reform in the US can be arrayed on the hedgehog/fox continuum. The most hedgehog-like example is probably the idea of shifting to a “market solution” based on consumer-directed health plans (CDHPs) where people have health spending/savings accounts (HSAs) and high-deductible coverage. This is intended to give them “more skin in the game” and thereby make them more prudent consumers of health care and spenders of their own money.
At its heart, this, like most hedgehog solutions, is appealingly simple, a single stroke that can make dramatic positive differences in the currently out-of-control healthcare costs. But to predict its overall effects, we should first look at precisely what it is supposed to change, and whether this single stroke is likely to do so. Clearly, the intent is to make dramatic differences in how consumers behave with respect to both their own health, and their healthcare utilization.
Ideally, the changes made in consumer health behaviors--in their diet, physical activity, tobacco/alcohol/drug use, driving, personal safety, management of stress, sleeping habits--will significantly reduce the incidence and prevalence of the diseases and injuries that create the need for and use of sickness care. Moreover, for those with existing chronic conditions, currently accounting for the vast majority of sickness care costs, increased adherence to prescribed medications and relevant lifestyle changes will reduce the crises, complications, and worsening of these conditions, and thereby further reduce the need for and use of sickness care.
One thing is clear, and that is that the use of “healthcare,” particularly that currently modest portion that is truly preventive and proactive in nature, should increase in order to reduce sickness care use and expense. So the changes in use of “healthcare” should be selective, not universal. Employers and insurers are already demonstrating their awareness of the need to be selective, in “value-based health benefit plans” that reduce or eliminate financial barriers to use of proactive disease-managing drugs, in contrast to reactive sickness care prescriptions.
But the real question that should be asked is whether shifting a significantly higher share of the sickness care cost burden to consumers will do the intended job. Will “punishing” them for being or getting sick, by forcing them to pay a larger share of the costs when they do so, turn them into healthier behavers? Given our admirable ability to deny to ourselves the likely consequences of unhealthy behaviors to our health and life quality, longevity, etc. will adding the threat of having to spend more of our personal wealth suffice to reform consumer behavior?
It has already been demonstrated that people who select CDHP/HSA coverage tend to be healthier and behave in a healthier fashion than those who prefer other insurance options. But some portion of this “effect” may simply be “self-selection bias”--the logical tendency of people who already behave more healthily and are in good health to choose CDHP/HSA coverage, since they can be more confident in their lower risk, compared to those who are not as healthy or do not behave as healthily.
We should look to experts in human behavior and behavior change for insights into whether a hedgehog solution such as shifting more costs of “unhealth” to consumers will actually do the trick. Future risks and negative consequences have not worked well in making us all law-abiding citizens, for example, despite the consequences being at least as dire as would be the case under greater consumer responsibility solutions.
Marketers, who are at least self-proclaimed experts in changing consumer behavior, would probably suggest a more complex and fox-like approach to promoting healthier behaviors and more prudent use of sickness care--one that would increase the extrinsic benefits of doing so, increase consumers’ awareness of the intrinsic benefits, or do both. Combining carrots and sticks usually works better than relying on sticks alone, particularly when it comes to making changes in regular behaviors, vs. rare “crimes”.
In any case, rather than focus on any simple (hedgehog) or complex (fox) “solution,” we should focus not on the solution, but on the problem. We need to address not only how consumers behave, for example, but on how providers behave, considering how much of sickness and health care use is driven by provider decisions and prescriptions. We need to address how governments and employers behave with respect to promoting vs. threatening the health of citizens and employees. We may even need to do so with respect to advertisers.
Any effort to dramatically reform consumer behavior, one that covers an incredibly broad range of different behaviors, as well as an incredibly diverse set of consumers (the American “melting pot”)--as well as of employers, providers, and governments--would seem to require a complex solution, vs. a simple one. Imposing more financial costs, and providing modest financial benefits as inherent in the CDHP/HSA “solution,” may be a useful element of a solution, but is not likely to suffice by itself.
In addition to asking experts in human behavior change, we might perhaps conduct some “market research,” into all those people whose behaviors must change--individual consumers, providers, employers, governments, etc. This should include both overt research, asking them what they think it would take to get them to change behavior, and perhaps even what they think it would take to get other stakeholders to change. But some covert research, based on “brain science,” on identification and analysis of the emotional and sub/unconscious, as well as conscious reasons for healthy vs. unhealthy behavior among all stakeholders would likely be useful as well.
Only when we clearly identify and understand the problem--which is the fact that nobody in the “healthcare system” is behaving the way they should--can we possibly gain the best chance of solving it. And when/if we achieve such understanding, it seems likely that a single hedgehog solution will not emerge as the best way to achieve the complex set of behavior reforms that will be necessary to succeed.
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