This is Kevin Volpp. Welcome to our course on behavioral economics and health. We're thrilled to have you join us. And I'm looking forward to teaching you what I can about behavioral economics, and how you can use it to help improve people's health. Let me start by giving you an example that may help understand where some of the opportunities are. Imagine you wanted to cure atherosclerotic cardiovascular disease, the cause of heart attacks, and the leading cause of death in the United States. If you controlled all research spending in the United States, would you put your research dollars into A, developing more effective treatments, B, developing a vaccine, or C, increasing adherence to existing therapies? Your answer to this question might depend on your answer to the next question. What percentage of patients take all their cardiovascular medications in the year following a heart attack? The response options here range from 90-100 percent, all the way down to below 40 percent. I find when I give this talk I get a wide range of responses. The more optimistic people in the audience will say 90-100 percent or 80-89 percent. Many clinicians will say, below 40 percent, or 40-49 percent. It turns out that unfortunately those clinicians are right. The best data on this, is from studies like the M-I free study which was led by Nitties Chowdry at Harvard Medical School, in which he convinced Aetna to run a massive social science experiment, in which all of their patients discharged from hospitals in the United States with heart attacks over the course of a year were randomized to either zero dollar copayments or standard copayments for their cardiovascular medicines. What he found was quite striking. The control group which got standard copayments had medication adherents levels of 39%, meaning that they only had filled prescriptions for 39% of the days in that year. That is likely an upper bound on their adherents, because there's no guarantee they took their medicines on all the days where they had a filled prescription. Making the medications free helps. And there's a statistically significant difference here. But it didn't help that much. It raised adherents from 39-45%. Hardly the game changer that one might have hoped for. There were also no significant differences in the rate of first major vascular event or revascularization. Because of statistics like this. When experts have estimated how much of premature mortality in the US is due to various factors, behavioral patterns loom very large. There are probably about 40% of the total. This is a broad definition of behavior including medication not adherence, but also including; smoking, drug use, behaviors leading to obesity, unsafe sex, eating habits and so on. You can see why it's challenging, to change all of those behaviors, but there's also a huge opportunity here, if we can figure out how to systematically improve healthy behaviors to improve population health. Raj Chetty and David Cutler did a very elegant study recently that was published in JAMA where they looked at differences in life expectancy within the U.S. based on income. What they found were huge differences in life expectancy among both men and women in the United States tied to their income. For men, the difference in life expectancy if you're in the first percentile of income versus the ninety nine percentile is about 15 years. For women, it's about 10 years. These are huge differences. What's also important to note, is they were mediated by behaviors like smoking, obesity and physical activity, and not mediated by access to health services per say. I think this really highlights the importance of these health behaviors as part of the production function of better health. People often don't do what you might expect them to do, or what their doctors or nurses might hope they will do. Why do people often do things that seem not to be in their own future self-interest. Through the lens of behavioral economics, we can better understand the limits of our rationality. In the next lecture, we'll start to talk about that, and get a sense of how behavioral economics has evolved. And how it both describes human behavior and provides a perspective for thinking about potential intervention strategies. Over the rest of the course, we'll examine a number of different areas where behavioral economics is being used, to both describe and influence human behavior in ways that can make it easier for people to help their future selves. Thank you.
