1. Building Theories by Breaking
Boundaries: Health and Wealth
Choice-Making
Punam A. Keller
Charles Henry Jones Third Century
Professor of Management
Tuck School of Business
Kunstler.com

2. Rise in Corporate Health Care Costs
2
Three factors are responsible for the increase:
 The formation of ACOs (Accountable Care Organizations)
are predicted to reduce competition among providers and
drive up payment rates,
 Medicare and Medicaid payment rates are expected to
decline relative to private payment rates, and
 Higher claims for stress-induced illnesses, which are highly
correlated to unhealthy behavior and adverse health
conditions such as heart disease.

3. Employee Inability to Retire has Increased
3
 Employment insecurity looms large: 42% identify job security as the most
pressing financial issue
 Twenty-five percent of workers in the 2012 Retirement Confidence Survey
say the age at which they expect to retire has changed in the past year. In
1991, 11 percent of workers said they expected to retire after age 65, and by
2012 that has grown to 37 percent.
 Worker confidence about having enough money to pay for medical
expenses and long-term care expenses in retirement remains well below
their confidence level for paying basic expenses.
 Although 56 percent of workers expect to receive benefits from a defined
benefit plan in retirement, only 33 percent report that they and/or their
spouse currently have such a benefit with a current or previous employer.

4. The “Official Syllogism”
More choice means more freedom
More freedom means more well-being
More choice means more well-being

5. Too Many Choices Can Make People Miserable
•Regret and
anticipated regret
•Opportunity costs
•Escalation of
expectations

6. ENABLE: Efficient-Novel-Active-Behavioral Levers
6
Segments
Behavior
Change
Interventions
Case Studies

7. Nonchalants
 Key trait is lack of motivation to pay
attention to health message.
 They are unconcerned or detached from
attempts to change their behavior.
 They are unlikely to engage in any health
message processing or provide any
response to the message unless
prompted to deliberate.
 Desirability of taking health action is
more important than feasibility for this
group.
7

8. Defensives
 They are motivated to change their
behavior, but believe they are not at risk
because they are unable to comply with
the behavior change recommendations.
 They engage in motivated reasoning
because they have low self-efficacy. Such
motivated reasoning may even take the
form of lower response efficacy because
they are unable to comply with the
recommendations.
 Feasibility of taking health action is more
important than desirability for this
group.
8

9. Status Quo Preservation Switching Cost Barriers
 Huh…
 I am fine…
 I like what I am doing…
 I have figured this out…
 I am chugging along…
 Don’t rock the boat…
 This works for me…
 I feel bad…
 I don’t know how…
 I have no self-control…
 It’s a habit…
 I will do it later…
 I will get less of something
else…
9
Two Groups of Behavior Change Barriers

10. Status Quo
Preservation
Deliberation
Prompts
Switching
Costs
Implementation
Aids
Behavior
Change
ENABLE: Efficient-Novel-Active-Behavioral-Levers
Framework

11. 11
Deliberation Prompts

12. Automatic - Effortful: Sample Modified Web Page to
Enroll in ReadyFill at Mail™
Added button – “I prefer to order my own refills” – to require members to
question whether the new behavior was more effortful.
Deliberation Prompt
 Easy/Clear/Fast
 Accurate Advantages
 Trustworthy
 Reversible

13. More members enrolled when new behavior was less
effortful than status quo
12.3%
22.3%
Control
N=4,232
Deliberation Prompt
N=6,950
Incremental Website Enrollment: Lift Over
Control
Deliberation
Prompt:
79%
more effective

14. CONTROL
“Press 1 if you would like to be
transferred to a Customer Care
Representative now.”
or
“Press 2 if you are not interested.”
“Press 1 if you prefer to refill your
prescriptions by yourself each time.”
or
“Press 2 if would you prefer us to do
it for you automatically.”
STABILITY
OF
PREFERENC
ES
Stable - Unstable: Modified Voice Recording to Enroll in
ReadyFill at Mail™
Deliberation Prompt
 Easy/Clear/Fast
 Accurate Advantages
 Trustworthy
 Reversible

15. 103%
more members
enrolled using
Deliberation
Prompt
Incremental IVR Enrollment in ReadyFill at Mail™: Lift over
Control
15.8%
32.0%
Opt-Ins
N=5,491
Enhanced Active Choice
N=4,459
22.1% 21.0%
Enrolled
Disenroll
ed
More members enrolled when reminded about unstable
preferences

16. Make the Default More Costly: Flu Shot Reminders
Opt-In Opt-Out Active Choice Enhanced Active
Choice
Place a check in
the box if you
want a reminder
to get a Flu
Shot.
Place a check in
the box if you
don’t want a
reminder to get a
Flu Shot.
Place a check in
one box.
I don’t want a
reminder to get a
Flu Shot.
I want a reminder
to get a Flu
Shot.
Place a check in
one box.
I want to remind
myself to get a
Flu Shot.
I want a reminder
to get a Flu
Shot.

17. Employees Had Higher Flu Shot Intentions
45%
60%
Opt-Ins Enhanced
Active
Choice
Incremental Flu Shot Reminders: Lift Over
Defaults
Enhanced Active
Choice:
50+%
more effective than
other options
52%
Active
Choice
Opt-Outs
93%

18. HWA Compliance: Opt-In vs. Active Choice Message
• Visit the Health and Wellness Assessment (HWA) website to develop an action plan to
maintain or improve your health. Now, or whenever you are ready, you will have free
access to powerful online coaching tools for success.
• If you have already completed or plan to complete the HWA, you will receive an annual
$200 off your bi-weekly or monthly health insurance contribution cost.
• The Health and Wellness Assessment is administered through HealthMedia and is
confidential. Results from all HWA responses will be summarized, without identifying
individuals, to determine trends in employee health.
 I prefer to take advantage of this free tool to maintain or improve
my health and save $200.
 I prefer not to take advantage and decline this opportunity to get
help in maintaining or improving my health and wellbeing.
18

19. HWA Compliance: Lift over Control and Control with
Financial Incentives
10.0%
27.0%
No Financial
Incentive
Jan-Sep 2010
Financial Incentive
Oct 2010
30%
Active Choice,
Financial Incentive
Nov-Dec 8 2010
Bundled HWA
with Commitment:
100%
increase with no
extra financial
incentive
HWA Compliance: Lift over Control and Control with Financial Incentives
19

20. Status Quo
Preservation
Deliberation
Prompts
Switching
Costs
Implementation
Aids
Behavior
Change
ENABLE: Efficient-Novel-Active-Behavioral-Levers
Framework

21. 21
Implementation Aids

22. 1. Select a 30 minute time slot right now to complete the online contribution to
your Supplemental Retirement Account (SRA) during the next week.
2. 3 minutes. Check to see if you have the following materials: a) worksheet
in your benefits packet _√_, and b) the name and social security number of a
beneficiary _√_.
3. Select the amount you want to invest for 2007 (minimum: $16/month,
maximum: $1,292/ month), even if you don’t know your take-home pay in your
first month. If you want, you can change this amount at a later date. This
voluntary contribution is tax-deferred, you will not pay taxes on it until you
withdraw the funds.
4. 5 minutes. Select a carrier. If you do not select a carrier, Dartmouth will invest
the non-voluntary portion of your college funds in a Fidelity Freedom Fund, a
fund that automatically changes asset allocation as people age.
5. 5 minutes. Now you are ready to complete your worksheet. Complete the
worksheet even though you may be unsure of some options. You can change
the options in the future.
6. Take your completed worksheet to a computer that is available for 20
minutes. If you like, you can use the one in the Human Resources office at 7
Lebanon Street, Suite 203.
7. 15-20 minutes. Log on to Flex Online and complete your online SRA
registration within the 20 assigned minutes. Be sure to click on the
investment company (TIAA-CREF, Fidelity, or Calvert) to complete the
application. You need to set up your account – otherwise your savings will not
reach the carrier.
We have outlined 7 simple steps to help you complete the application.
Implementation Plan to Prompt Implemental Mindset
22

23. Dartmouth Employees Share Stories about How They
Save for Retirement 23

24. SRA Compliance: Lift over Control and Implementation
Plan
20.7%
31.0%
Seven Steps
(no video)
2006-2007
Video New
Employee Orientation
Jan – June 2008
Simple Plan
280%
more effective
Videos of Employee
Stories:
55%
more effective than
Seminar/New
Employee
Orientation File
SRA Compliance: Lift over Control and
Implementation Plan
7.3%
Control
2005-2006
24

25. Implementation Aid for HWA
Incremental Enrollees
Lift over control
30.0%
58.0%
Champion
Letter
Mail with
How- To
Instructions
Incremental Enrollees
Lift over control – 93.3%
25

26. Implementation Aid for Biometric Screening
26
40.0%
51.0%
Champion
Letter
Mail with
Barriers
Incremental Enrollees
Lift over control – 93.3%

27. NYSE: Financial Fitness Toolkits

28. NEFE: Employee Well-Being

29. ENABLE: Efficient-Novel-Active-Behavioral Levers
29
Segments
Behavior
Change
Interventions
Case Studies