“Nudging” Improves Care in the Prior Authorization Workflow

For centuries, theories on how we make decisions have been heavily influenced by work done by economists looking to understand and predict the behavior of markets. The original premise is that, when faced with a decision between multiple options or behaviors, people will always choose the option that will maximize their return. But, people are people. We’re not calculators. Your decision on what to have for breakfast is influenced more by where items are placed in your refrigerator than what would be nutritionally optimal.

We, as people, bring a host of preconceptions, desires, and cognitive biases to any decision we make. In fact, we are likely to make different decisions based on simple things like the time of day, the organization of information on a screen, or the phrasing of choices. Those idiosyncrasies and unconscious biases present opportunities to influence behavior and are the focus of modern behavioral science.

Behavioral scientists, often referred to as behavioral economists, have amassed a great deal of research on how seemingly-simple changes to the phrasing or presentation of information can influence behavior. We at Cohere utilize those findings to improve both the efficiency and quality of care that health plans cover for their members. In addition, our approach also improves both the provider experience and medical expense savings generated from our platform beyond current approaches.

Specifically, we build “nudges” into the authorization workflow that not only increase the completeness and accuracy of the authorization submission, but also guide the provider user to optimal sites of care, and to alternative services based on the patient’s risk profile. These nudges are designed with the principles of behavioral economics front and center. The placement within workflow and on the screen, the specific framing and benefits we highlight in the text, and the look and placement of buttons are all deliberately designed and rigorously tested to optimize acceptance by our users and thereby improving the quality and timeliness of care for patients.

The impact of behavioral science within healthcare

Taking this approach not only increases the likelihood of clean, instantly processed authorization submissions, it increases the quality of care received by our health plan clients’ members. Simultaneously, we reduce unnecessary medical costs.

Specifically, Cohere Health’s intelligent UM platform has been proven to drive 15% incremental medical savings beyond incumbent programs, with 63% fewer denials. Physician adoption and satisfaction are both well above 90%, and, most importantly, the impact for patients is clear:

• 70% faster access to care
• 43% reduction in medically unnecessary surgeries (arthroscopy)
• 18% reduction in complication rate (total hip & knee replacement)
• 11% shift of inpatient to outpatient surgery (arthroplasty)

Download our recent case study to learn more.

1: Witynski, Max. “Behavioral Economics, Explained.” University of Chicago News.

2: Rosalsky, Greg. “The Behavioral Economics Manifesto Gets Revised.” NPR, NPR, 27 July 2021.

3: “Impact.” Center for Health Incentives and Behavioral Economics, 15 Feb. 2021.

4: “Impact – Health Systems.” Center for Health Incentives and Behavioral Economics, 15 Feb. 2021.

5: Thaler, Richard H., and Cass R. Sunstein. Nudge: Improving Decisions about Health, Wealth, and Happiness. Yale University Press, 2008.