Payer How To: Letter Samples That Increase Responses

Including deadlines and addressing the ostrich effect are among the changes that improve outcomes.

HealthLeaders recently reported on BCBS-MA's Nudge Unit, a first-of-its kind initiative that "uses behavioral insights to present information in new ways." This information, deployed in multiple customer communications, "can lead to improved decision-making and better health outcomes."

In addition, here are specific Nudge Unit examples—provided by BCBS-MA—that illustrate the small wording changes. The plan reports that these updates increased at-home colorectal cancer screening by 3%, with 500 more test kits returned.

The plan's Nudge Unit initiative involved the mailing of a revised letter and fecal immunochemical test (FIT) to complete the home-based screening. The revisions incorporated behavioral science research on the importance of deadlines and the unintended impact of communicating health risks.

Revision 1: Deadline language

"Procrastination impacts us all," says Rebecca Oran, director of the Nudge Unit and Behavioral Insights at BCBS-MA. "Deadlines help to solidify next steps and avoid planning fallacy, or our tendency to underestimate how long it will take to complete a task. The most effective deadlines are often far enough away that individual has time to act, but not so far away in the future that it could lead to procrastination."

Oran cites research (example one and example two) that has found that individuals are more likely to complete an action if there are deadlines included. As a result, BCBS-MA updated the following language in its FIT test mailing: 

• Usual letter: No deadline language
   
• Nudge letter: Added "Please return the included kit in the next 3 weeks."

Revision 2: The ostrich effect

Another BCBA-MA letter revision tapped into avoidance behavior.

"People often avoid taking actions that could result in unpleasant or negative news, such as positive test results," says Oran.

"Medical communications often include information about risk as a way to encourage patients to consider the consequences of not taking action and encourage them to do. However, that information sometimes has the opposite effect—patients feel more apprehensive about completing preventative screenings and in turn, avoid the screening all together (or "ostrich").

Oran adds: "Although it may seem counterintuitive, the ostrich effect has been empirically documented across various contexts from goal setting to investing."

The following was an additional change to the BCBS-MA FIT test mailing:

• Usual letter: "Colorectal cancer is the second-leading cause of cancer deaths in the United States. However, it's also one of the most preventable and, when diagnosed early, survival rates can be as high as 90%."
   
• Nudge letter: Removed this language.

Beyond letters

Getting customers to open a letter from their health plan, much less read it, is an ongoing payer challenge. For other Nudge Unit interventions, BCBS-MA has varied the outer envelope to get better results.

BCBS-MA's Nudge Unit is updating other communication vehicles as well.

"More broadly," says Oran, "the Nudge Unit has applied behavioral science across a variety of communication channels (emails, letters and faxes) as well as through digital channels (such as our member portal and public-facing website)."

These are among the Nudge Unit wins that BCBS-MA aims "to refine and scale," per Oran.