Clinical Outcomes Improvement

Vaccination: Good for the community, the industry and your bottom line

February 13, 2023 9:56 am

Jacob Braude, a principal at ZS, returns to the podcast to discuss his firm’s latest research on vaccine hesitancy.

Mentioned in this episode:

The real reason people don’t get vaccinated for COVID-19? They don’t feel like it.

A cognitive research playbook for encouraging hesitant customers to get COVID-19 boosters

Erika Grotto: A booster episode about vaccination research, today on HFMA’s Voices in Healthcare Finance podcast. 

Hello, and welcome to the podcast. I’m your host, Erika Grotto. In 2022, I interviewed Jacob Braude from ZS about what drives people to get vaccinated. In today’s episode, Jacob is back on the podcast discussing his company’s latest research on the topic. But first, let’s find out what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack. 

Nick Hut: Hey, everyone. Our topic of discussion today is health equity and the increasingly central role it’s taking in a healthcare regulatory context. Of course, the push to make healthcare more equitable really accelerated near the start of the pandemic, when the disparities in COVID-19 rates and outcomes among different population segments and demographics became difficult to ignore. And around the same time, the death of George Floyd made more people view inequity throughout society, including in healthcare, really a matter of justice. So a recent noteworthy development on this front is that in January, the Joint Commission announced it would be elevated healthcare equity to become one of the commission’s designated national patient safety goals for hospitals, effective July 1. It doesn’t have a practical impact, necessarily, on requirements that actually had just gone into effect for accredited organizations on January 1, but it elevates the issue to the same tier as, for example, infection prevention. So Shawn, what do you think of the significance here?

Shawn Stack: Nick, I think that, you know, the Joint Commission is definitely joining all the other initiatives wrapping around health equity for many of the reasons that you just stated—the lens that health equity took during the pandemic and the systemic issues that we witnessed as part of the pandemic around health equity. The program is a voluntary certification, and it will go into play July 1 of 2023. I mean, hospitals can reach out and have the Joint Commission send them the pre-published standards to review now if they log on to the website and show interest in the program. And they can pre-apply, of course, for that certification program early this year. So it is a step forward in the health equity lens. The programs kind of recognize that hospitals and critical access hospitals, they’re going to recognize those that strive for excellence in their efforts to provide the healthcare services through a health equity lens. So it’s very good news for us.

Hut: Another aspect of this topic to mention, we know CMS under the current administration has made health equity a strategic pillar, and for this fiscal year—in other words, starting last October—hospitals have had to report on three equity-related measures to receive the maximum Medicare payment for inpatient services. Also, last December, the agency proposed establishing a health equity index that would factor into the star ratings for Medicare Advantage and Medicare Part D plans. So everyone should be aware that this increasingly is becoming an operational mandate, not just for the sake of doing right by your patients and community but also to stay on top of regulatory requirements. Shawn, anything to add before we kick it back to Erika? I know HFMA’s got something brewing on this front as well.

Stack: Yeah, so I’m working with Community Catalyst out of Boston, and we are getting ready to launch a new health equity research study and best practices development, and that research project that I’m heading up with Community Catalyst is really centered on advancing health equity through responsible financial assistance, billing/collections policies, and then SDOH screening policies. So we’re going to be partnering with the Robert Wood Foundation and possibly another sponsor that I can’t announce yet, that’s really focused on the health equity and social determinants of health factors. So that’s some exciting news coming up for HFMA and our members here.

Hut: Alright, well, thanks for sharing that news, Shawn. Definitely an exciting news development upcoming for HFMA. So thanks, everybody. We will talk to you in a couple weeks.

Grotto: As I record this, the CDC’s latest figures show that only 15.5% of the total population has received an updated booster dose of the Covid-19 vaccine. Comparatively, 69.2% have completed the primary series of vaccines, and 81% have received at least one dose. There’s some variation by age group, but even the most likely population to get vaccinated—those age 65 and older—have not been as likely to receive a bivalent dose. 94.2% completed the primary series, but only 40.1% have been boosted.  And no matter what number shot we’re talking about, the younger you are, the less likely you are to have gotten it. As we await the word on what’s next for protection against Covid, I wanted to know more about what makes people decide to get vaccinated, or not, and called on a former guest to explore this with me. Jacob Braude is a principal at ZS,  a consulting services firm with a specialization in life science. ZS has been doing research into how unconscious parts of the brain affect decisions around vaccination, and some of the results were surprising. If you haven’t listened to my conversation with Jacob, or haven’t heard it since it came out, it’s definitely worth revisiting. We’ll link it in the show notes. ZS’s research includes all sorts of vaccines, but given those CDC numbers, it seems more important than ever to understand what goes into the decision making process, and as you’ll hear, the continued research is enlightening. 

First of all, I am really excited to have you back on the podcast. The episode that we did last year is one of the ones that I talk about the most when people ask me about what I do for a living because the takeaways were so fascinating. And now every time I end up like getting a shot or taking my kids for a shot I think about it.

Jacob Braude: That’s a great association.

Grotto: So can you review, for anybody who didn’t listen to that episode or maybe hasn’t listened to it since it came out, can you tell the audience a little bit about your original research on vaccine hesitancy—when you did it, what it was for, and some of the high level findings?

Braude: Earlier, before we started recording, you were talking about that lawyer who turned himself into a cat. So it goes back to those days. Nobody wants to remember them, but back in the pandemic days, the early pandemic days when the vaccines first rolled out and we were seeing such a difficult time really engaging people and gaining enough trust to get enough of an immunity to really benefit from the vaccines, we did a global study, 6,000—6, 7,000 people—and we looked at different types of behavioral nudges that could help influence people to feel more comfortable getting vaccinated. We looked at adult vaccines like shingles. We looked at pediatric vaccines like the ones your kids get. And we looked at Covid. And back then, it was just your first dose of Covid. The whole booster thing didn’t even exist. And we tested 19 different well known cognitive factors to see which ones worked. And the big surprise was that there was only one that actually worked for all three types of vaccination, but each one had its own set of nudges that made people feel comfortable getting vaccinated.

Grotto: I’m curious what the uptake—and this is kind of a side note—but I’m curious what the uptake on what the shingles vaccine is going to be this year among Medicare patients because changes in the payment have made it free if you have a Medicare Advantage plan or Part D prescription coverage. I know I’ve been telling my parents every since I got shingles, get the shingles vaccine because you don’t want shingles.

Braude: No, you don’t.

Grotto: But it was cost prohibitive. So I told them, OK, January 1. Go get it. So tell me, kind of, what you’re doing now as follow-up. Have you continuously looked at this or did you take a pause and go back. You’re working with boosters now, right?

Braude: So just to answer your first question, the early data is that the shingles uptake looks very strong.

Grotto: Oh, good. I didn’t think you would have an answer for that. I was just musing. But I’m glad that you do, and I’m glad for anybody who might get shinges, ‘cause—

Braude: I think we should spend the end of this podcast planning on how you’re going to nudge your parents to get the vaccine.

Grotto: I’ll call them live.

Braude: We could turn it into one of those kinds of shows. We did want to continue the research, so last year, we looked at two different things. So one, we looked at boosters. I’m sure you’re familiar—the uptake of boosters has been far less than the uptake of the initial vaccine. I think the communication has been scattered, and people feel less threatened, and so we’re seeing much less protection against the different variants of Covid through the use of boosters than I think we were hoping to see. So we wanted to look at that, and we looked at two different situations, because we had a hypothesis. One is, Covid’s out there. It’s scary. You’re hearing about it on the news. People are getting infected. What works in that situation? And kind of the one we’re in now, which is like, eh, Covid’s out there. So is RSV. So is the flu. What kinds of things would nudge folks to get boosted if they’re not being pressured by the environment? They’re not constantly seeing sick people in the news like we were back in the day. So we ran both scenarios, and that was pretty interesting. And then the other part of the puzzle that we totally neglected last time is, the healthcare provider. We know these conversations are hard. If you get a signal from somebody that they might be against vaccines, even if that’s a successful conversation, it’s not gonna be the highlight of your day. But it’s important. So how do we get folks on the front line who know they’ve got a vaccine hesitant patient in there or consumer in their clinic, how do we get them to invest 4-5 minutes in listening to them and talking to them about this, because it goes a long way for personal and public health if they’re successful.

Grotto: What did you learn? Is there anything surprising here? Any big a-ha moments? Is there hope?

Braude: Is there hope? There is hope. We did see significant—same as last time. I think there’s a group of people who feel very comfortable with vaccines. There’s a group of people who feel very uncomfortable, and then there’s the large, mushy middle who has some questions or hesitations or maybe just some friction barriers that even during Covid, a lot of the people who still weren’t vaccinated, when we went to ask them, why are you not vaccinated yet, they didn’t have any objections, they just couldn’t fit it into their day. So there are a number of different opportunities to improve vaccination, which is good for the community if you’re running a health system. It’s good for the community and the health system and the bottom line, so it’s got a lot of positive benefits if you can nudge folks. One of the big surprises to me is that, all of the things that would work for people if Covid was going crazy also worked if Covid was sort of in the background. But you also needed this extra set of stuff that would work when Covid was in the background that you didn’t need to turn on if Covid was in the media. That was interesting. I kind of expected it to be totally different, but it wasn’t. It was just like, like a booster. Ha ha. Sorry. Like a booster that you needed in order to make it effective.

Grotto: Can you expand on that a little? Kind of illustrate that a bit?

Braude: Yes. So some of the interesting ones, so there’s a concept called moral regulation, which is basically like, Dr. Pepper uses this on their cans. So if you go look at a can of Dr. Pepper, it’s got a bunch of compliments to you on the back like, you drive your grandma to work, and, you know, you make dinners for people or whatever. I don’t know what they’ve got on there. But because a lot of people have this instinct of balancing good and bad choices, so drinking a—whatever it is, 20 grams of sugar, I don’t even know how much is in a 12-ounce can. It’s a lot of sugar. Drinking one of those people would feel guilty about if you’ve had enough education. Most people are like, eh, I probably shouldn’t be drinking soda. But if I’m getting reminded of those other good things I do, then that makes it feel like, well, I deserve this. It’s OK. So we wanted to look at that. Like maybe there’s a relationship between people who see getting vaccinated as morally good and willingness to get vaccinated. That one held out. So folks are like, yeah, getting vaccinated is good for the community. It’s a good thing to do. It’s not just about me selfishly. And those folks are much more willing to go, even go get the booster, even if it’s your fourth, fifth shot. If science is saying you need it, they’re like, OK, I’ll go get it. I thought that one was interesting. The other one that went along with that is something they call it the affect heuristic. If you’ve seen the Geico commercials, that’s what that is. People make different choices if they’re in a good mood. So like, Geico doesn’t try to actually sell you their insurance very hard. They just try to give you a laugh and then be like, “Geico.” Because you start to associate that feeling with the product even though they’re not actually related.

Grotto: Do vaccines need a funny animal mascot?

Braude: Maybe. Maybe. I don’t know. People who were in more positive affective state were much more likely to get vaccinated when presented the opportunity than people who were in a negative one. So we did a test awhile back with a well known video streaming brand. They were looking to drive subscriptions, and one of the things we tested was affect. And so we put people in either a good or bad mood and then offered them the service, and in Japan—only in Japan—putting people in a bad mood actually made them more likely to subscribe to the service because it was seen as a luxury there. And so just like, you know, in your bad mood, you reach for the ice cream, that service was the ice cream over there. And so that’s how it worked. So I think vaccines are not ice cream. So if people are in a bad mood they’re going to be much more likely to turn it down. That might be something to teach physicians to look out for. Try to find the peak good mood portion of the exam or the wellness discussion and then let’s talk about vaccines there. Maybe don’t talk about it as a door handle kind of a conversation or, oh, your blood pressure’s high, let’s also talk about vaccines—probably not a good sequence if you really want to get them vaccinated.

Grotto: You talked about kind of the unpleasant conversation, but do you have any indication of what communication is like amongst healthcare providers and patients around vaccination? And I shared with you before we started recording that I learned today—on January 26, 2023—that for more than a month now, updated boosters have been available for children 6 months to 5 years. I did not know that, and I have a four year old. I’ve been waiting and watching, but I’ve gotten no communication from the pediatrician or the health system or anything, and somehow I missed it in the news. But how communicative are providers willing to be about vaccines—whether it’s just, hey, this is available, or hey, you really ought to get this?

Braude: You’re touching on a couple of things, and I think it would be interesting to name your health system. I wonder if the executives there are listening to this. Maybe they could step in. You’re touching on a couple of things. So even just fielding the study with doctors required us to refield it a couple of times because everybody says that they’re going to have these vaccine conversations. And we know that they don’t, but you don’t want to look like the doctor who doesn’t, and so just saying like, would you have this conversation, 100% of people said yes. We’re like OK, this is not going to work. We can’t—so we actually had to set the situation up as kind of a hard one. Like, you’re going to really spend a lot of time with a hesitant patient on a wellness visit just to do that. So it’s impossible to really understand how willing doctors are to communicate because they’re all going to say “very willing.” Because that’s the socially acceptable thing to say. We did have a really interesting finding in the study where, in the patient part of the survey, we asked questions and then the doctor side, we asked the same questions about the patients. So we asked stuff like, how well do your patients understand the science behind vaccines, how well did they understand the safety. All those sorts of things. And doctors thought that patients didn’t understand the science, that they didn’t know about a lot of the facts about vaccines whereas patients said that they did. So right away there’s a disconnect there. The interesting part is, doctors thought that patients had enough safety information to decide, but patients said that they didn’t. So doctors think that the problem is, patients don’t understand the facts. Patients are like, no, no, I understand the facts. My problem is, I don’t know if I feel safe with this. Doctors are like, they totally understand the safety of it. And so you get this big disconnect where they’re just like not talking to each other.

Grotto: Yeah.

Braude: And that creates a big gap.

Grotto: And I wonder who’s right about the understanding of the science. It could probably be both. You know.

Braude: Yeah.

Grotto: Patients probably think they understand, you know, just as I think I understand the science behind it, but I certainly wouldn’t explain it the same way my doctor would. And if you asked my doctor, do I understand it, she would probably say well, no, because I don’t have a medical background. So I don’t know. I don’t know that I’m looking for an answer, but I’m just curious what does it mean to understand the science.

Braude: I think the real question is, does it matter? When they say that they understand the science, I think to a doctor it matters a lot. That’s their job—to understand the science, to judge it, and then make decisions based off of it. I think a lot of people are making these decisions instinctively, emotionally. And so when they say, the part that I don’t really know enough about is safety, what they’re saying is, I still feel anxious about this. And is really explaining the science going to be the way that makes me not feel anxious about it, or are there are other things that you could do like, for example, framing it within a moral context, putting me in a good mood, actually emphasizing the effort that was put in during Covid. We found that that helped drive boosters. So if you’re like, look, you’ve done a lot of work to stay healthy during this pandemic. This is part of that. People are like, oh yeah, OK, yeah, I have done a lot of work. Alright, that makes sense. Let’s do this. So I think it’s those kinds of shifts that we need to help our providers understand how to make.

Grotto: Yeah. And that is, I’m reminded, in our last conversation, that was something that you brought up, where people kind of think they’re making these decisions based on facts and science, but really they’re just kind of acting on their instincts or impulses. I don’t know the right way to put it, but I think the way you put it was, people will get vaccinated if they feel like it.

Braude: Look at everything else in your life.

Grotto: Yeah.

Braude: You know? I think we run on about 20 watts of power, the human brain. I don’t remember if we talked about this last time.

Grotto: We did. We talked about Watson and Jeopardy!

Braude: Yeah. 200,000 watts. We have to rely on instinct to make most of our decisions. I just think that’s not taught in medical school, and so you know, we’re seeing a lot of our health systems and payers start to put together nudge units because they recognize this. They need providers and patients to take healthy behaviors if they’re going to have the impact that they want to have. And a lot of times, the problem is that they don’t. It’s not that they don’t know what to do. It’s that they don’t do it. And that’s where the nudge units could be really helpful.

Grotto: So we’re talking to an audience mainly of providers. What are the takeaways here? Is it that physicians should be talking with their patients more? Is it that a health system should be working this into their communication plan? What do we do, if the goal is to vaccinate more people?

Braude: I think there’s two pieces, and they both are for the health system. I think asking the providers to become experts in this is—they’ve got a lot on their plate already. I think it’s really, what are the tools and the education that we’re providing for them that can make this easier for them. Like, how do we just be smarter as administrators? So for example, one of the ones that worked is called mere measurement effect, which is basically, if you ask somebody how  likely they are to do something, it increases their likelihood. They did a survey with people, how likely are you to buy a car in the next six months, and then they compared them to people who weren’t surveyed. Those people bought more cars. That was one of the tests we ran, just saying, like, that’s something that your health system could do. “How likely are you to get vaccinated?” can actually increase people’s willingness and interest in getting vaccinated, just by getting asked. And that’s something you don’t have to ask the doctor to even handle. You know, we can just take that off their plate. I think the other piece is like, how do we help make the vaccine discussion behavior more likely? So like, one of the tests we did with doctors is something called embodied cognition, which is basically, what metaphors do you use when you talk about this? Because it’s a window, right, so if you talk about crime as a virus, people think you need more social reform programs, whereas if you say crime is a beast, they think you need more cops. So the metaphor you use has a lot to do with how you’re going to treat it. So we asked them, what metaphors do you use for these conversations? When you think about a conversation with a vaccine-hesitant patient, what do you think about? They were really discouraging. Talking to a brick wall, taming a rabid dog. You know, like, imagine that someone’s like, OK, Erika, today your job is to have a five-minute conversation that’s gonna be like taming a rabid dog.

Grotto: I mean, that’s not what you wanna add to your day.

Braude: No. No. And even when we asked them, OK, you had a successful conversation with a vaccine-hesitant patient, and they got vaccinated. Give us a metaphor. A quarter of them still gave us talking to a wall. So even just thinking about having it work, it’s like, yeah, but I don’t feel great about it. Some guys were like, ice cream on a hot day or that kind of a thing. So some people had the right framework, but even one of the things that we can do for them is trying to help use positive metaphors to just change their mindset around having these conversations. How many conversations were skipped? If it’s taming a rabid dog, and I’m like, I could spend five minutes here or I could just say goodbye, great to see you, and go get some paperwork done, that paperwork’s looking really good to me versus this rabid dog conversation. There were a few other ones with doctors that surprised us, like, there’s this concept called cognitive dissonance where trying to hold two competing ideas in your head feels uncomfortable, so you could either ignore it or you just resolve it one direction or the other. So for example, if you say to a doctor like, do you agree that you know how your patients feel about the treatments you prescribe them, they say yes. And then if you say to them, do you agree that your patients don’t always tell you everything about how they feel, they say yes. And you say, OK, how are those two things the same? And you’ll get them to go, OK, maybe I’m overestimating how much I know about how they feel. And that works here too. If you confront them with the conflict, you know, like, do you know who’s gonna say no to vaccines, yes. Have you had a bunch of conversations where you thought they’d say no and they said yes? Yeah, I have. Well, those two things can’t exist. So you must—And it gets them to come in with an open mind rather than coming into the conversation going OK, like talking to a brick wall again. Let’s see if I can get out of this. That’s the thing you want to avoid, is that assumption that they know how it’s gonna go.

Grotto: This is all so, so interesting, and I know there’s probably so much more to it. I do want to ask you one more question, because I want to know, what is next? Are you continuing to look at this issue?

Braude: We are. I think it’s a big one. I think it’s just important to a lot of people. I think the next step for us is, let’s get out of research and let’s try some of these ideas. I think it was last year, maybe two years ago, Wharton did a really nice test where they sent text messages to a bunch of customers of a health system and then tracked who actually came and got vaccinated. So you could literally see what are the actual phrases that we can use that are gonna get folks to come in here and follow up, and the one that worked the best was, hey, we set aside a dose for you. So if you felt like someone had already done some work on your behalf and they were reserving it for you, you were like, I guess I gotta go in there. So starting to road test a bunch of these ideas within real health systems and pharmacies I think would be the next step. So if anyone’s listening and you’re interested, let’s talk about how we can try some stuff.

Grotto: I would love to hear more about what you learn as you continue because, you know, I’d love to think that Covid vaccines and flu vaccines and shingles or pneumococcal or whatever is the end of it, but there’s more. There’s more. There’s always gonna be more.

Braude: Yeah. It’s a game. I hope your parents get vaccinated.

Grotto: Oh, they will. Jacob Braude, thank you so much for coming back and updating me on this. This is such an interesting topic and I think it’s one our listeners are going to be excited about hearing.

Braude: It’s always a pleasure talking to you. Thanks for having me.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Additional writing and research are done by Nick Hut, Shawn Stack and the HFMA editorial staff. Sound editing is by Linda Chandler. Brad Dennison is the director of content. Our president and CEO is Joe Fifer. Registration is open for our June Annual Conference in Nashville. We have so many exciting things planned; you can’t afford to miss it. You can register now at 

Reading this blog post is like ice cream on a hot day

ZS, a consulting services firm with a specialization in life science, has been conducting research on vaccine hesitancy since the first vaccine for COVID-19 came out. As the firm’s work continues, Jacob Braude, a principal at ZS, discussed the team’s findings on HFMA’s “Voices in Healthcare Finance” podcast.

The research

ZS conducted a global study in 2020 and 2021 to determine which behavioral nudges could encourage people to get vaccinated for COVID-19 and other illnesses. Their findings were covered on a 2022 episode of the podcast. The firm’s continued research focused on boosters, which have not had the uptake the original vaccines did.

“I think there’s a group of people who feel very comfortable with vaccines,” Braude said. “There’s a group of people who feel very uncomfortable,” he added. “And then there’s the large, mushy middle [that] has some questions or hesitations or maybe just some friction barriers.”

Reaching the people in the middle group is integral to improving vaccination uptake, he said.

Concepts that work

People tend to make decisions based on feeling rather than fact, Braude said. That means appealing to people’s feelings could make them more open to vaccination. ZS’s research showed that people who see getting vaccinated as morally good are more willing to get a shot. People also are more likely to answer in the affirmative if they’re asked to get a shot when they’re in a good mood, Braude said.

“That might be something to teach physicians to look out for,” he said. “Try to find the peak good mood portion of the exam or the wellness discussion and then let’s talk about vaccines there.”

The physician’s role

ZS also found that physicians are unlikely to ask about vaccination if they believe a patient will be hesitant. Many physicians surveyed by ZS compared speaking to such patients as “taming a rabid dog” or “talking to a brick wall,” Braude said.

“One of the things that we can do for [physicians] is trying to help use positive metaphors to change their mindset around having these conversations,” he said. “If it’s taming a rabid dog, and I could spend five minutes here or … go get some paperwork done, that paperwork’s looking really good to me versus this rabid dog conversation.”

Even successful conversations that ended with a patient getting a shot didn’t result in positive metaphors for many physicians, Braude said. Although a few compared those conversations to “ice cream on a hot day,” others still used the rabid dog comparison.

Another necessary mindset change is helping physicians go into vaccination conversations without assumptions about whether the patient will respond positively or negatively, he said.

Next steps

Braude plans to continue researching vaccine hesitancy by taking some concepts that a survey said would work and testing them with real healthcare organizations.


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