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The 4th D

Decision-making is the fourth "D" of health care, after Drugs, medical Devices and Doctors

By Jeannie Kever

As policy makers confront health care’s thorny nexus – how to improve the health of millions of Americans while controlling costs – one group of researchers is focused on a variable that gets little attention: consumer decision-making.

“Drugs, devices and doctors are critical elements of the solutions. But a series of decisions surround their use,” said Partha Krishnamurthy, director of the Institute for Health Care Marketing and a professor of marketing at the University of Houston.

Call decision-making the fourth “D” of health care, after drugs, medical devices, doctors and other health care professionals.

The Institute for Health Care Marketing, a research center based in the UH Bauer College of Business, applies the principles of academic marketing research to questions that can improve the quality of health care. The issue isn’t whether one drug should be more frequently prescribed than another, or which hospital gives off a warm-and-fuzzy vibe. Instead, the research deals with such topics as improving diagnostic accuracy, reducing the stigma surrounding mental illnesses, and how required drug testing affects chronic pain patients and their willingness to return for the next appointment.

Betsy Gelb, Larry J. Sachnowitz Professor of marketing at Bauer, has been part of the institute since it began in the early 1990s. As health care and society have changed, the institute’s focus has changed as well, and Gelb said some of today’s most critical issues surrounding the Affordable Healthcare Act are ripe for study.

“It’s an uncertain future, so of course it’s a marketing issue,” she said.

‘Life and death decisions’

And the stakes couldn’t be higher.

“It’s a multi-trillion dollar industry in which the buyers make life and death decisions,” said Edward Blair, chairman of both the institute and the Department of Marketing and Entrepreneurship.

Hospital and health care systems were growing rapidly in the 1990s – Hermann Hospital and Memorial Health Care System merged in 1997, shifting the ground in Houston and creating one of the nation’s largest not-for-profit health care systems – but the use of marketing to learn more about patient behavior was still in its infancy. “They didn’t know if they wanted to be in that business,” Gelb said.

Academic marketing was – and is – strikingly different from its corporate counterpart, and soon Gelb, the first director of the institute, and Blair were conducting polls to determine knowledge and attitudes about local hospital systems. How best to encourage patients to adhere to medical regimens or to show up for preventive health screenings were other popular topics of the era, Blair said.

That data allowed them to study other issues, too; one of Gelb’s early findings offered insight into how much attention people pay to news coverage when they don’t feel a personal connection.

The institute’s early polling coincided with a scandal involving a local psychiatric hospital accused of patient dumping, among other complaints. By comparing data collected on public attitudes before, during and after the heavily publicized charges, she determined that most attitudes were unchanged because few in the public had a personal connection to the charges.

They saw and read the coverage, but they didn’t really absorb it, she said.

Understanding how and when people pay attention to the news remains important information. So is work Gelb did through grants from the University of Texas MD Anderson Cancer Center, focused on cancer prevention.

One attempted to determine the best way to communicate the dangers of ultraviolet rays in an effort to prevent skin cancer. Cancer prevention specialists didn’t like the idea of a color-coded scale – they felt there should be no “green means go” for sun exposure, Gelb said – but the research also determined there are limits to using numerals, especially a 1-100 scale. “In Houston in the summer, 86 sounds like no big deal when people think about the temperature, so they would think it was no big deal if you told them the UV danger was 86,” she said.

A second study yielded more conclusive results: If you want people who work outdoors to take precautions against sun exposure, including wearing long sleeves and caps, communicate the message to their spouses. “That raised the odds that good advice would actually be taken,” Gelb said.

Now the field is opening to broader issues of policy and health care economics.

How people choose health insurance, and how that choice relates to their behavior, may yield information crucial to understanding health care economics, Blair said. Do people with high deductibles, for example, behave differently than those who choose an HMO with low out-of-pocket costs?

“Little research has been done on people choosing insurance,” he said. “I think that will be more important in the future.”

Choosing between two options

Krishnamurthy arrived at UH in 1997 with an academic focus on consumer research.

At the time, academic marketing research routinely used undergraduate students as study subjects but Krishnamurthy, curious about how people choose between two options with varying levels of risk and expected outcome, wanted to use subjects facing real decisions. And he was interested in health care.

He wasn’t affiliated with the Institute for Health Care Marketing at the time, but he set up and conducted the study with Blair and Patrick Carter, now chief of family medicine and medical director for care coordination and quality improvement at Kelsey-Seybold Clinic.

The study used two groups of subjects – undergraduates and patients. The results, published in 2001 in Organizational Behavior and Human Decision Processes, shed light on how decisions are framed, including on the stark differences between decisions made by subjects with little skin in the game – students, answering questions about hypothetical decisions – and those made by real-life patients.

The methodology, as much as the result, drew attention; Krishnamurthy said peer-reviewed marketing academic journals at the time targeted rigorous theory and methodology rather than outcomes, which could vary depending on the study subjects. That has begun to change as researchers focus more on choosing subjects and framing questions in order to produce meaningful results, he said.

But that study also had another outcome: Krishnamurthy was hooked on health-care research using real patients, and Blair asked him to join the institute. He also is an adjunct faculty member at the University of Texas Medical Branch and is affiliated with the Center for Research, Innovation and Scholarship in Medical Education at Baylor College of Medicine.

The institute isn’t funded by health care companies or other special interests, Krishnamurthy said. Instead, it serves as a think tank devoted to improving health care.

“We’re not interested in getting people to buy more prescription drugs, to go to the doctor more, or in improving the bottom line of a hospital,” he said. “Instead, it is, How can we improve the quality of health care that is delivered?”

Answering that question gets at the essence of academic marketing.

“Marketing is the science of finding complementary competencies so that everybody is better off,” he said. “All of society is essentially a marketplace. Otherwise, we’d be in our own caves, making our own fires.”

Academic researchers aren’t trying to sell communal caves and fire wood. They are interested in what Krishnamurthy calls “a deep dive into what makes the consumer tick, and what makes firms tick.”

Partha Krishnamurthy

Working on today’s hot topics

So far, they have discovered information about a range of health care issues, including mental illness, drug addiction and false positive health screenings.

Gelb began her work on the stigma surrounding mental illness after a phone call from a woman leading group therapy sessions at a local nonprofit. The clients all had been previously hospitalized for depression, the caller told Gelb, but did not want to use their health insurance benefits to cover the follow-up sessions. The insurance funding would have been good for the agency’s budget, but the women didn’t want people they worked with to know they had struggled with depression.

It was a clear ah-ha! moment for Gelb, who suddenly had a new project to pursue during an upcoming sabbatical.

“It’s OK, even attractive, to break a leg when you are skiing,” she said. “But if the chemicals in your brain are messed up, you’re expected to apologize or hide.”

Working independently and with Patrick Corrigan, director of the National Consortium for Stigma and Empowerment at the Illinois Institute of Technology, Gelb has published several papers considering strategies to challenge the stigma, suggestions for using advertising to reduce the stigma, and approaches managers can take to reduce stigma and, it’s hoped, reduce the costs of mental illness.

Among her findings: Some advertising campaigns designed to reduce the stigma actually made the problem worse. And while an ineffective ad for a particular product risks little more than wasting money, bad ads dealing with mental illness could have lasting consequences, she wrote in the Journal of Current Issues and Research in Advertising.

A positive call to action – akin to “Only you can demand respect for people coping with a mental illness” – was more effective than accusing the audience of false perceptions. Another suggestion was to link a diagnosis of mental illness with a condition that doesn’t have such a stigma; Gelb noted the headline on an ad in Forbes: “Imagine if diabetes were seen as a sign of personal failure.”

Creating ways for people to openly and safely share their experiences with mental illnesses is another key, she said. “Once people are able to say, ‘This is something I have,’ the scary goes away.”

Krishnamurthy’s recent research has touched on the stigma surrounding mental illness but has also tackled other health care issues.

In a study involving patients treated for anxiety and published last year in the Journal of Clinical Psychology, he found patients who improve quickly are more likely to drop out before completing cognitive behavioral therapy, losing the potential for future benefit.

Betsy Gelb

Mental speed bumps

The stigma associated with mental illness may be one reason, he said. Although the study did not offer direct evidence, he suggested patients might think of the stigma and reason, “I’ve gotten better, so why should I continue being seen seeking treatment?”

A second study, conducted with UTMB physicians Dr. Gulshan Doulatram, Dr. Ranganathan Govindaraj and Dr. Courtney Williams and published earlier this year in Pain Physician, found chronic pain patients monitored through urine drug screenings – standard protocol to ensure patient safety – is linked to an increase in the odds that the patients won’t return for future treatment.

Two current studies in the Texas Medical Center address decision-making even more explicitly. One at Texas Children’s Hospital, conducted with Dr. Satid Thammasitboon, Dr. Corey Chartan and Dr. Moushumi Sur, involves asking hospital residents after they have conducted a medical exam if they might have missed any “red flags,” or significant information.

“The idea is to build in mental speed bumps,” Krishnamurthy said, directly asking the residents to stop and think about the exam before entering a diagnosis. “In this case, the physician is a consumer of information, trying to make decisions.”

The “speed bump” led to more accurate diagnosis, he found. Accurate diagnosis is linked to fewer complications, shorter hospital stays and lower mortality.

A second project considers using more than one opinion when interpreting mammograms initially flagged for further testing. Having three radiologists rather than one read the suspicious films – and agreeing to abide by the consensus of two of the three – resulted in significantly fewer false positive readings, Krishnamurthy said.

Considering the price tag for additional testing spurred by a false positive reading, he said the system would also save money, despite the cost for the additional radiologists’ time.

“In the collective, there is a certain wisdom,” he said.

There is a certain wisdom, too, in expanding the focus of health care research to consider how and why people make the decisions they do.

The traditional emphasis on the hard sciences – biology, chemistry, anatomy – is crucial, Krishnamurthy said. “Vaccines are a textbook example of how basic science can make a big difference.”

But the anti-vaccine movement, which has prompted some parents to refuse to vaccinate their children out of the belief that vaccines are too risky, illustrates the power of consumer behavior, he said.

“These types of problems are 100 percent marketing and decision-making problems, but no one thinks of it as that,” he said. “Our goal is to study the ‘4th D,’ decision-making, both at the institutional and patient level to help keep the client population healthier.”

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