How to Promote Home Delivery of Prescription Drugs? Give Employees a 'Nudge'

Bob Nease, chief scientist at Express Scripts wants to promote home delivery of prescription drugs by mail—a process proven to lower error rates, increase cost savings, and improve medication adherence. But, if switching to home delivery is beneficial to most employees, why don’t more of them do it? Associate Professor John Beshears describes how using choice architecture, or nudging people, can guide employees to making wiser decisions while still respecting their autonomy.

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Transcript edited for clarity

Brian Kenny: What if your doctor told you that you had a chronic disease that could debilitate or even kill you, but that it was 100 percent treatable if you took prescribed medication, indefinitely. Would you take it? Would you keep taking it? If you're like 50 percent of people in the United States who are in that very situation, the answer is, "no." According to a recent study in the Annals of Internal Medicine, nonadherence to prescribed medications is itself an epidemic, leading to as many as 125,000 deaths a year. The same study showed that 20 to 30 percent of prescriptions are never even filled. So, if the threat of sickness or death isn't enough to compel people to take their medication, what is?

Today we'll hear from Professor John Beshears about his case entitled Express Scripts, Promoting Prescription Drug Home Delivery. I'm your host, Brian Kenny, and you're listening to Cold Call.

John Beshears is an expert in behavioral economics, the field that combines insights from psychology and economics to explore individual decision-making. In that vein, he has studied participation in retirement savings plans, household investment decisions, and, of course, health care choices. John, thanks for joining us today.

John Beshears: Thanks for having me.

Kenny: I think many people are going to be able to relate to this case. I'm one of those people who's on chronic medication. And I'd like to report that I do take it; so, for me, I got in the habit, but apparently, a lot of other people don't. Could you start by telling us who the case protagonist is and what's on their mind?

Beshears: The case follows Bob Nease, the chief scientist at Express Scripts, which is one of the major players in the pharmacy benefit management industry. He's working with one of Express Scripts largest clients, a retailer. At this retailer, many employees regularly get prescription medications for the types of chronic conditions that you mentioned: hypertension, diabetes. They get these medications by showing up, month-in month-out, at a brick-and-mortar pharmacy. Nease is trying to figure out how to get employees to switch to using the Express Scripts mail delivery service for their prescriptions. This is beneficial to the large retailer, and it's also beneficial to its employees.

The key question is, if making the switch to home delivery is beneficial to most employees, why aren't more of them already making the switch? If you look at the time of the case, all of the employees were taking these medications for chronic conditions; only 6 percent of them were taking advantage of the home-delivery service. Nease wants to figure out how they can increase that number as much as possible. This is a case about human behavior, and I think the specific problem that Nease faces is emblematic of a much wider class of problems. Here we have people who are engaging in a behavior that seems counterproductive, relative to their own self-interest. How can leaders in an organization set up employees to make wiser decisions?

Kenny: How did you hear about Express Scripts? What led you to write this case?

Beshears: I have conducted a research study on exactly this situation. When I first learned about it through a colleague, I thought, well, at the same time (that this is) a wonderful academic article, this makes a beautiful case study. As I mentioned, I think the problem that Nease faces is this perfect microcosm of a pervasive problem in organizations. All the incentives seem to be in place for people to make a wise decision, but the good behavior fails to materialize; so what can a leader do? And then, also, the specific issue at hand is important in its own right. If you look at total spending in the US on prescription medications, it was approaching $400 billion last year. That's about 10 percent of overall spending on the US health care system, and about 2 percent of US GDP.

If we look at prescription drug spending as one of the fast-growing components of health care costs, we realize that we really, desperately need ways to contain this cost, while simultaneously improving health outcomes. And then, just lastly, I think the solution that Nease and his team come up with is a beautiful application of behavioral economics. And, as you say, we're trying to build insights from psychology, insights from economics into ways of helping people reach better outcomes by designing the environment in which they make decisions. We call this sometimes using choice architecture, or nudging people, trying to guide them to these wiser decisions, while respecting their autonomy. Nease and his colleagues just provide a great example of how successful this approach can be.

Kenny: Tell us a little bit about the PBM sector, because Express is one of three major players in that space, right?

Beshears: Express Scripts is one of the leaders in this industry. But, just to back up and explain what a pharmacy benefit manager does, it's responsible for coordinating this web of relationships, individuals, firms, that are involved in helping people get prescription drugs through their health plan. The clients of a PBM are both employers and health insurance companies, but maybe we can take the case of an employer, like that retailer that Nease was working with. Employees at this company who want to participate in the health plan can make an upfront premium payment and the retailer will contribute to that as well, and part of this goes towards their prescription drug plan.

What they get is a card, which says that they're entitled to prescription drug benefits. So, when they go to the Walgreens or the CVS to pick up a prescription, they present their card, they provide a copayment on top of that, and then the pharmacy hands over their medications. The focus of this case is the other option for employees, the possibility of having the PBM be the one to directly mail the medications to the employee's home.

Kenny: Let's say you're the employer in this case; why is it advantageous for you to do it that way?

Beshears: The employer wants to contain costs for the prescription drug benefit while improving the health of the employee population, and home delivery is going to hit on both of those points. There's evidence that mailing prescriptions to people's homes makes them take their medications more regularly. It also turns out that, because it's done by a machine as opposed to by a human, there's a safety improvement. You're getting the right dose, you're getting the right medication.

On the cost side, mail orders are filled at this gigantic distribution facility, and that saves money simply because it's more efficient than the traditional brick-and-mortar model. You can pass along those savings to employees, and keep some of those savings for yourself, as the employer. And finally, if Express Scripts has an individual in its mail order system, that makes it easier for Express Scripts to encourage other sorts of cost-saving moves, like switching from a brand name drug to a therapeutically equivalent generic drug. All of this is, of course, increasing Express Scripts' revenues. They have a direct business interest in this.

Kenny: I wonder if they looked into whether or not there are some misperceptions about this. You go to the pharmacy, walk up to the counter, and see the person putting the pills in the jar for you. You have a level of comfort there, versus this all happening in some big factory somewhere; I don't know if I'm getting quality medications.

Beshears: Absolutely. And there are totally real, genuine reasons why going to the brick-and-mortar pharmacy is beneficial. It's not just comforting, but maybe the friendly neighborhood pharmacist can provide you with a little bit of advice about the side effects of medication. I think there's a lot of initial hesitation to make the move from picking up your drugs in-person, to having them mailed to your home. Some of that might be a security concern: You don't like the idea of a box of medication sitting on your front doorstep while you're not at home. Or, maybe, you live in a large apartment building and you feel it's a little bit of a violation of your privacy for your neighbors to see. It's an inconspicuous box, but it's a box of medications, nonetheless, and they might note that, or even ask questions about it.

On the other hand, the person who adopts home delivery gets all of these benefits. And one final thing I'll highlight, and maybe this resonates with you; it certainly resonates with me. We all have hectic lives; mail delivery is just more convenient. You don't have to show up once a month at the pharmacy; the prescription comes right to your door.

Kenny: From the employer standpoint, why don't they just take a strong stand? Why don't they just say, "This is the way we're doing it, like it or not, this is how you're going to get your medication."

Beshears: That's certainly something that a handful of employers did take as their approach. I think a lot of firms feel that perhaps it's not conducive to employee morale. But it often just falls back on this gut feeling that that's not the way to run a benefit program, to be so forceful, or even punitive.

Kenny: The case also points out that there are … real dollars at stake here, too, for employers. It's in the hundreds of billions of dollars each year that can be attributed to people getting sick, missing time, missing productivity because they don't take their medications. So, they definitely want to figure out a solution. Which brings us to the notion of nudging. Talk a little bit about that.

Beshears: Nudging is a term that was coined by Richard Thaler and Cass Sunstein in the book they wrote in 2008 called Nudge. [Editor's note: Thaler on October 10 won the Nobel prize in economics for his work on nudging specifically and behavioral economics in general.] The idea is that we should recognize that humans are imperfect decision-makers, and we know this from decades of research documenting that we are all subject to psychological biases. And beyond that, it's also easy to see that we're bombarded by information every day. It's way too much information for us to process completely. We routinely make mistakes, and we make mistakes in a systematic direction. For example, we underinvest in behaviors like healthy eating, exercise--that are challenging to implement today but that deliver benefits in the future.

Now, the good news. It all sounds discouraging up until this point, but the good news is we can use our understanding of the way humans behave to redesign the environment in which decisions are made, and guide people to better outcomes. So, maybe we change the way options are presented to people. Maybe we change the process by which options are selected from the menu. These are examples of nudges or changes to the choice architecture.

Kenny: You've looked at this and other areas aside from health care. I know, I've read some of the articles that you did in Working Knowledge. Can you talk a little bit about other ways that you've seen this applied?

Beshears: One of the most widely used examples of nudging is automatically enrolling people in an employer-sponsored retirement savings plan, like a 401(k). What used to happen in 401(k) plans is a new employee would arrive at the company and would receive this thick packet of paper, its benefits-related information, and they'd have to figure out a way how to process all of that information. But, they'd be told, "We have a retirement savings plan; it's a great employee benefit. If you'd like to participate, tell us what fraction of your pay you'd like to contribute and how you'd like to invest those contributions." And it's a pretty daunting task, so a lot of people would be slow to get around to enrolling. I've looked at the data for a typical company around one year of tenure; employees are typically participating at a 40 percent, or a 50 percent, or a 60 percent rate.

Kenny: Surprising, wow.

Beshears: Especially when you consider the fact that they're leaving employer-matching dollars on the table. Those are things like an instantaneous 100 percent or 50 percent rate of return on your investment. What people do now is they flip this; they automatically enroll employees using a Scripts ... Kind of like this: "Welcome to the company. Unless you tell us to do something else, we are going to automatically contribute 6 percent of your pay to your 401(k) account every pay cycle. We'll invest it in a target-date retirement fund, and you can opt out, you can tell us you want a different contribution rate or a different investment option, but if you don't tell us anything, that is what we're going to do for you."

Notice what this does. The only thing we've done is changed the default; we've changed the option that's implemented if an employee does not actively choose some other option. But the employee has retained complete freedom of choice. All the options that used to be available are still available, but we've nudged the employees to participate in the plan. It's something that they wanted to do anyway, but we just made it a little bit easier for them. And when you look at the data, indeed, automatic enrollment makes just night-and-day difference, when it comes to plan participation. I mentioned at a one-year tenure, maybe it's a 40 percent, 50 percent, 60 percent participation rate of the plan. That goes up to around 95 percent, maybe even higher.

Kenny: Wow.

Beshears: And the average savings rate in the plan increases, too, so employees are on a path to a more secure retirement.

Kenny: So, you haven't taken the decision out of the hands of the employee, but you've taken the anguish of the thought process while they're going through all these other adjustments in their life. They don't have to deal with that; it's done for them. How did Express Scripts apply the same notion?

Beshears: They recognized the key barrier to adopting the prescription drug home delivery program was a simple lack of bandwidth. And it comes back, again, to the fact that employees, people in general, lead busy lives. Switching to home delivery is just one of many different things that they could pay attention to. What Nease and his colleagues had to do was figure out a way to insert themselves into those busy lives of employees in a way that grabbed their attention.

When you look at the results of how they implemented this new choice architecture, Express Scripts was able to generate pretty impressive numbers from the program when it was implemented at the large retailer. Among employees that are taking these medications for chronic conditions, the fraction who were using the home delivery program went from 6 percent to 40 percent.

Kenny: Wow.

Beshears: I've calculated out that the employees and the employer, collectively, were saving about $1 million per year as a result, approximately split equally between employees and employer. The key insight that emerges from the case is exactly how Express Scripts inserted itself in this way that captured attention. The way it did it, without giving too much away, is that it took advantage of the existing touch points it had with individuals. The overarching process it went through was diagnosing the barriers to wise decisions in this case--that was preventing people from taking up home delivery--then designing the choice architecture with those barriers in mind, ultimately delivering the program using existing structures.

Kenny: It seems like there would be tremendous opportunity to apply the same thing in many, many different ways.

Beshears: Yes.

Kenny: I would love it if you say a couple of remarks about behavioral economics, this field. It seems a number of faculty have come in over the last 10 years (practicing in this field). It seems to be an area of research that is exploding in some ways.

Beshears: As soon as you think about the fact that there is increasing recognition of all of the limitations of human decision making, you realize that understanding that more deeply, and then turning that understanding into insights about how you can help people make better decisions, is a wide-open area. I've done some calculations looking at the type of return on investment, so to speak, one gets from using nudge interventions. The ones that are currently deployed are delivering tremendous returns, sometimes more than 100 times per dollar spent impact when you're moving important outcomes like retirement saving, like energy, like getting people to enroll in college.

There just seems to be a large number of opportunities out there to apply these ideas. The excitement and the rush into this area that you've noted is really reflecting the fact that we still think there's a lot of room to grow here.

Kenny: John, thanks for joining us today.

Beshears: It was absolutely a pleasure; thanks for having me.

Kenny: You can find the Express Scripts case, along with thousands of others in the HBS case collection at HBR.org. I'm Brian Kenny, your host, and you're listening to Cold Call, the official podcast of Harvard Business School.

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Transcript edited for clarity

Brian Kenny: What if your doctor told you that you had a chronic disease that could debilitate or even kill you, but that it was 100 percent treatable if you took prescribed medication, indefinitely. Would you take it? Would you keep taking it? If you're like 50 percent of people in the United States who are in that very situation, the answer is, "no." According to a recent study in the Annals of Internal Medicine, nonadherence to prescribed medications is itself an epidemic, leading to as many as 125,000 deaths a year. The same study showed that 20 to 30 percent of prescriptions are never even filled. So, if the threat of sickness or death isn't enough to compel people to take their medication, what is?

Today we'll hear from Professor John Beshears about his case entitled Express Scripts, Promoting Prescription Drug Home Delivery. I'm your host, Brian Kenny, and you're listening to Cold Call.

John Beshears is an expert in behavioral economics, the field that combines insights from psychology and economics to explore individual decision-making. In that vein, he has studied participation in retirement savings plans, household investment decisions, and, of course, health care choices. John, thanks for joining us today.

John Beshears: Thanks for having me.

Kenny: I think many people are going to be able to relate to this case. I'm one of those people who's on chronic medication. And I'd like to report that I do take it; so, for me, I got in the habit, but apparently, a lot of other people don't. Could you start by telling us who the case protagonist is and what's on their mind?

Beshears: The case follows Bob Nease, the chief scientist at Express Scripts, which is one of the major players in the pharmacy benefit management industry. He's working with one of Express Scripts largest clients, a retailer. At this retailer, many employees regularly get prescription medications for the types of chronic conditions that you mentioned: hypertension, diabetes. They get these medications by showing up, month-in month-out, at a brick-and-mortar pharmacy. Nease is trying to figure out how to get employees to switch to using the Express Scripts mail delivery service for their prescriptions. This is beneficial to the large retailer, and it's also beneficial to its employees.

The key question is, if making the switch to home delivery is beneficial to most employees, why aren't more of them already making the switch? If you look at the time of the case, all of the employees were taking these medications for chronic conditions; only 6 percent of them were taking advantage of the home-delivery service. Nease wants to figure out how they can increase that number as much as possible. This is a case about human behavior, and I think the specific problem that Nease faces is emblematic of a much wider class of problems. Here we have people who are engaging in a behavior that seems counterproductive, relative to their own self-interest. How can leaders in an organization set up employees to make wiser decisions?

Kenny: How did you hear about Express Scripts? What led you to write this case?

Beshears: I have conducted a research study on exactly this situation. When I first learned about it through a colleague, I thought, well, at the same time (that this is) a wonderful academic article, this makes a beautiful case study. As I mentioned, I think the problem that Nease faces is this perfect microcosm of a pervasive problem in organizations. All the incentives seem to be in place for people to make a wise decision, but the good behavior fails to materialize; so what can a leader do? And then, also, the specific issue at hand is important in its own right. If you look at total spending in the US on prescription medications, it was approaching $400 billion last year. That's about 10 percent of overall spending on the US health care system, and about 2 percent of US GDP.

If we look at prescription drug spending as one of the fast-growing components of health care costs, we realize that we really, desperately need ways to contain this cost, while simultaneously improving health outcomes. And then, just lastly, I think the solution that Nease and his team come up with is a beautiful application of behavioral economics. And, as you say, we're trying to build insights from psychology, insights from economics into ways of helping people reach better outcomes by designing the environment in which they make decisions. We call this sometimes using choice architecture, or nudging people, trying to guide them to these wiser decisions, while respecting their autonomy. Nease and his colleagues just provide a great example of how successful this approach can be.

Kenny: Tell us a little bit about the PBM sector, because Express is one of three major players in that space, right?

Beshears: Express Scripts is one of the leaders in this industry. But, just to back up and explain what a pharmacy benefit manager does, it's responsible for coordinating this web of relationships, individuals, firms, that are involved in helping people get prescription drugs through their health plan. The clients of a PBM are both employers and health insurance companies, but maybe we can take the case of an employer, like that retailer that Nease was working with. Employees at this company who want to participate in the health plan can make an upfront premium payment and the retailer will contribute to that as well, and part of this goes towards their prescription drug plan.

What they get is a card, which says that they're entitled to prescription drug benefits. So, when they go to the Walgreens or the CVS to pick up a prescription, they present their card, they provide a copayment on top of that, and then the pharmacy hands over their medications. The focus of this case is the other option for employees, the possibility of having the PBM be the one to directly mail the medications to the employee's home.

Kenny: Let's say you're the employer in this case; why is it advantageous for you to do it that way?

Beshears: The employer wants to contain costs for the prescription drug benefit while improving the health of the employee population, and home delivery is going to hit on both of those points. There's evidence that mailing prescriptions to people's homes makes them take their medications more regularly. It also turns out that, because it's done by a machine as opposed to by a human, there's a safety improvement. You're getting the right dose, you're getting the right medication.

On the cost side, mail orders are filled at this gigantic distribution facility, and that saves money simply because it's more efficient than the traditional brick-and-mortar model. You can pass along those savings to employees, and keep some of those savings for yourself, as the employer. And finally, if Express Scripts has an individual in its mail order system, that makes it easier for Express Scripts to encourage other sorts of cost-saving moves, like switching from a brand name drug to a therapeutically equivalent generic drug. All of this is, of course, increasing Express Scripts' revenues. They have a direct business interest in this.

Kenny: I wonder if they looked into whether or not there are some misperceptions about this. You go to the pharmacy, walk up to the counter, and see the person putting the pills in the jar for you. You have a level of comfort there, versus this all happening in some big factory somewhere; I don't know if I'm getting quality medications.

Beshears: Absolutely. And there are totally real, genuine reasons why going to the brick-and-mortar pharmacy is beneficial. It's not just comforting, but maybe the friendly neighborhood pharmacist can provide you with a little bit of advice about the side effects of medication. I think there's a lot of initial hesitation to make the move from picking up your drugs in-person, to having them mailed to your home. Some of that might be a security concern: You don't like the idea of a box of medication sitting on your front doorstep while you're not at home. Or, maybe, you live in a large apartment building and you feel it's a little bit of a violation of your privacy for your neighbors to see. It's an inconspicuous box, but it's a box of medications, nonetheless, and they might note that, or even ask questions about it.

On the other hand, the person who adopts home delivery gets all of these benefits. And one final thing I'll highlight, and maybe this resonates with you; it certainly resonates with me. We all have hectic lives; mail delivery is just more convenient. You don't have to show up once a month at the pharmacy; the prescription comes right to your door.

Kenny: From the employer standpoint, why don't they just take a strong stand? Why don't they just say, "This is the way we're doing it, like it or not, this is how you're going to get your medication."

Beshears: That's certainly something that a handful of employers did take as their approach. I think a lot of firms feel that perhaps it's not conducive to employee morale. But it often just falls back on this gut feeling that that's not the way to run a benefit program, to be so forceful, or even punitive.

Kenny: The case also points out that there are … real dollars at stake here, too, for employers. It's in the hundreds of billions of dollars each year that can be attributed to people getting sick, missing time, missing productivity because they don't take their medications. So, they definitely want to figure out a solution. Which brings us to the notion of nudging. Talk a little bit about that.

Beshears: Nudging is a term that was coined by Richard Thaler and Cass Sunstein in the book they wrote in 2008 called Nudge. [Editor's note: Thaler on October 10 won the Nobel prize in economics for his work on nudging specifically and behavioral economics in general.] The idea is that we should recognize that humans are imperfect decision-makers, and we know this from decades of research documenting that we are all subject to psychological biases. And beyond that, it's also easy to see that we're bombarded by information every day. It's way too much information for us to process completely. We routinely make mistakes, and we make mistakes in a systematic direction. For example, we underinvest in behaviors like healthy eating, exercise--that are challenging to implement today but that deliver benefits in the future.

Now, the good news. It all sounds discouraging up until this point, but the good news is we can use our understanding of the way humans behave to redesign the environment in which decisions are made, and guide people to better outcomes. So, maybe we change the way options are presented to people. Maybe we change the process by which options are selected from the menu. These are examples of nudges or changes to the choice architecture.

Kenny: You've looked at this and other areas aside from health care. I know, I've read some of the articles that you did in Working Knowledge. Can you talk a little bit about other ways that you've seen this applied?

Beshears: One of the most widely used examples of nudging is automatically enrolling people in an employer-sponsored retirement savings plan, like a 401(k). What used to happen in 401(k) plans is a new employee would arrive at the company and would receive this thick packet of paper, its benefits-related information, and they'd have to figure out a way how to process all of that information. But, they'd be told, "We have a retirement savings plan; it's a great employee benefit. If you'd like to participate, tell us what fraction of your pay you'd like to contribute and how you'd like to invest those contributions." And it's a pretty daunting task, so a lot of people would be slow to get around to enrolling. I've looked at the data for a typical company around one year of tenure; employees are typically participating at a 40 percent, or a 50 percent, or a 60 percent rate.

Kenny: Surprising, wow.

Beshears: Especially when you consider the fact that they're leaving employer-matching dollars on the table. Those are things like an instantaneous 100 percent or 50 percent rate of return on your investment. What people do now is they flip this; they automatically enroll employees using a Scripts ... Kind of like this: "Welcome to the company. Unless you tell us to do something else, we are going to automatically contribute 6 percent of your pay to your 401(k) account every pay cycle. We'll invest it in a target-date retirement fund, and you can opt out, you can tell us you want a different contribution rate or a different investment option, but if you don't tell us anything, that is what we're going to do for you."

Notice what this does. The only thing we've done is changed the default; we've changed the option that's implemented if an employee does not actively choose some other option. But the employee has retained complete freedom of choice. All the options that used to be available are still available, but we've nudged the employees to participate in the plan. It's something that they wanted to do anyway, but we just made it a little bit easier for them. And when you look at the data, indeed, automatic enrollment makes just night-and-day difference, when it comes to plan participation. I mentioned at a one-year tenure, maybe it's a 40 percent, 50 percent, 60 percent participation rate of the plan. That goes up to around 95 percent, maybe even higher.

Kenny: Wow.

Beshears: And the average savings rate in the plan increases, too, so employees are on a path to a more secure retirement.

Kenny: So, you haven't taken the decision out of the hands of the employee, but you've taken the anguish of the thought process while they're going through all these other adjustments in their life. They don't have to deal with that; it's done for them. How did Express Scripts apply the same notion?

Beshears: They recognized the key barrier to adopting the prescription drug home delivery program was a simple lack of bandwidth. And it comes back, again, to the fact that employees, people in general, lead busy lives. Switching to home delivery is just one of many different things that they could pay attention to. What Nease and his colleagues had to do was figure out a way to insert themselves into those busy lives of employees in a way that grabbed their attention.

When you look at the results of how they implemented this new choice architecture, Express Scripts was able to generate pretty impressive numbers from the program when it was implemented at the large retailer. Among employees that are taking these medications for chronic conditions, the fraction who were using the home delivery program went from 6 percent to 40 percent.

Kenny: Wow.

Beshears: I've calculated out that the employees and the employer, collectively, were saving about $1 million per year as a result, approximately split equally between employees and employer. The key insight that emerges from the case is exactly how Express Scripts inserted itself in this way that captured attention. The way it did it, without giving too much away, is that it took advantage of the existing touch points it had with individuals. The overarching process it went through was diagnosing the barriers to wise decisions in this case--that was preventing people from taking up home delivery--then designing the choice architecture with those barriers in mind, ultimately delivering the program using existing structures.

Kenny: It seems like there would be tremendous opportunity to apply the same thing in many, many different ways.

Beshears: Yes.

Kenny: I would love it if you say a couple of remarks about behavioral economics, this field. It seems a number of faculty have come in over the last 10 years (practicing in this field). It seems to be an area of research that is exploding in some ways.

Beshears: As soon as you think about the fact that there is increasing recognition of all of the limitations of human decision making, you realize that understanding that more deeply, and then turning that understanding into insights about how you can help people make better decisions, is a wide-open area. I've done some calculations looking at the type of return on investment, so to speak, one gets from using nudge interventions. The ones that are currently deployed are delivering tremendous returns, sometimes more than 100 times per dollar spent impact when you're moving important outcomes like retirement saving, like energy, like getting people to enroll in college.

There just seems to be a large number of opportunities out there to apply these ideas. The excitement and the rush into this area that you've noted is really reflecting the fact that we still think there's a lot of room to grow here.

Kenny: John, thanks for joining us today.

Beshears: It was absolutely a pleasure; thanks for having me.

Kenny: You can find the Express Scripts case, along with thousands of others in the HBS case collection at HBR.org. I'm Brian Kenny, your host, and you're listening to Cold Call, the official podcast of Harvard Business School.

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