By Jessica Greene – Baruch College, City University of New York
Ellen Peter’s article “Educating Good Decisions” is focused on addressing the challenging dynamic of public policies that increasingly rely on people to make informed choices, despite many people not having strong decision-making skills. One illustrative example of this situation in the U.S. is the Affordable Care Act’s state health insurance exchanges. Consumers are encouraged to select the highest quality, most affordable health plan so that they enroll in the plan that best meets their needs and to spark competition among health plans in the market. Peters and colleagues, however, previously documented that of the prime group to enroll in exchange health plans, uninsured adults, fewer than 9% had sufficient numeracy skills to calculate which plan would be the most cost-effective for them.
At the beginning of her article, Peters compares educating consumers to make good decisions to helping someone jump over track and field hurdles. She explains that you can help someone clear a hurdle by either: 1) lowering the hurdle, which makes the task easier, or 2) strengthening the runner. The analogous approaches in the decision-making context, she argues, are making the information easier for people to understand, like lowering the hurdle, or improving peoples’ decision-making skills.
I like this construct for thinking about how to improve consumers’ abilities to make decisions. But, neither strategy is easy to implement.
Simplifying educational and decision-making information for consumers is not always straightforward. There is a growing evidence base of strategies that reduce the cognitive burden of decision-making information, for example by reducing the amount of information presented and not using technical language (see for example reviews by Kurtzman and Greene; or Hibbard and Peters). However, experimental studies have shown that approaches that seem intuitive to information providers (and researchers studying decision-making) do not always support informed choice. For example, a well-cited 2007 paper by Peters and colleagues found that using traffic light symbols to indicate the quality of hospitals helped only those higher in numeracy select the highest quality hospital and may have hurt those lower in numeracy. Studies have also demonstrated that consumers’ perception of what information is easy to understand and useful is not always consistent with their comprehension of the information (see for example Greene, Peters, Mertz and Hibbard; or Hanoch, Rich, Cummings and Wood). Thus, focus group and other qualitative testing of educational materials have the potential to identify approaches that consumers are comfortable with, but not that necessarily support better comprehension or informed choices. Quantitative testing of educational materials is what is needed, yet it is not commonly done.
Improving people’s decision-making skills, which is the second strategy, is substantially more challenging. One way to do this would be to improve the educational system in the U.S., where Peters points out there is much room for improvement (fewer than half of high school graduates were considered college-ready in math). However, this has been a largely unrealized goal of the last two presidents (Dragoset et al.; Dee and Jacob), and according to a recent article in the Washington Post, most states have no clear plan now on how to fix troubled schools. In the best case scenario, if public education were to improve (which would have many benefits beyond improving the quality of decision-making), it would take a number of years to trickle down to improving decision-making.
A second approach Peters discusses for improving decision-making skills is to improve adults’ numeracy ability, since numeracy skills have been shown to be causally related to decision-making quality and are modifiable. This direction seems quite promising, and I look forward to reading Peters’ new work in this area once it is published. If effective, however, it would likely be challenging to get people, particularly those with poor numeracy skills, to participate in math-based training programs.
In sum, both avenues to educating good decisions are important to pursue, but neither are easy to accomplish. They should be complemented by other ways to “lower the hurdle” of complex decision-making. One such way is to reduce the number of options from which consumers choose. There are a number of policy contexts, like Medicare prescription drug plans, where experts have called for policy makers to limit the number of plans that are offered, and/or standardize the benefits to make comparing plans more straightforward. Another approach is using behavioral economic strategies to encourage or “nudge” people towards desired behaviors and to default people who do not make a choice into beneficial options. By combining policies that make choices easier with education for good decisions we hopefully can get to better consumer decision-making, and stop leaving those with lesser skills behind.
Peters E, Meilleur L, Tompkins MK. Numeracy and the Affordable Care Act: Opportunities and Challenges. July 2014. http://www.ncbi.nlm.nih.gov/books/NBK224823/. Accessed October 1, 2015.
Kurtzman ET, Greene J. Effective presentation of health care performance information for consumer decision making: A systematic review. Patient Educ Couns. July 2015. doi:10.1016/j.pec.2015.07.030.
Hibbard JH, Peters EM. Supporting informed consumer health care decisions: data presentation approaches that facilitate the use of information in choice. Annu Rev Public Health. 2003;24:413-433.
Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care Res Rev. 2007;64:169-190.
Greene J, Peters E, Mertz CK, Hibbard JH. Comprehension and Choice of a Consumer-Directed Health Plan: An Experimental Study. Am J Manag Care. 2008;14:369-376.
Hanoch Y, Rice T, Cummings J, Wood S. How Much Choice Is Too Much? The Case of the Medicare Prescription Drug Benefit. Health Serv Res. 2009;44(4):1157-1168. doi:10.1111/j.1475-6773.2009.00981.x.
Dragoset L, Thomas J, Herrmann M, et al. School Improvement Grants: Implementation and Effectiveness. Washington, DC; 2017. https://ies.ed.gov/ncee/pubs/20174013/pdf/20174013.pdf.
Dee TS, Jacob BA, Kinner F, et al. The Impact of No Child Left Behind on Students, Teachers, and Schools. Brookings Pap Econ Act. 2010;2010(2):149-194. doi:10.1353/eca.2010.0014.
Brown E. What should America do about its worst public schools? States still don’t seem to know. Washington Post. https://www.washingtonpost.com/local/education/what-should-america-do-about-its-worst-public-schools-states-still-dont-seem-to-know/2017/08/06/db2d6dcc-76c6-11e7-8839-ec48ec4cae25_story.html?utm_term=.0e14f0c698d5. Published August 6, 2017.