The world is full of excessive or unjustified frictions that make life difficult to navigate. Those frictions include stifling administrative burdens that prevent people from getting where they want to go or doing what they want to do.
In behavioral economics, there’s a new word for those burdens: sludge.
When the intended action is harmful (say, buying a weapon with the intention of murdering someone), some forms of sludge — like background checks or mandatory waiting periods – can be for the public good. But when the intended action is beneficial, such as signing up to be an organ donor, sludge that delays or inhibits the outcome can be very bad.
Employees, students, small businesses, patients, nurses, doctors, and developers are often frustrated or even defeated by form-filling requirements accompanied by incomprehensible instructions. The best way to fight back is through “sludge audits,” which enable both companies and governments to catalogue the overall costs of administrative burdens and help show whether they are justified.
Under federal law, the Office of Management and Budget is required to produce a kind of national sludge audit, known as the Information Collection Budget of the United States. The ICB catalogues the annual paperwork burden that the government imposes on its citizens, and does so on an agency-by-agency basis.
The latest report, from 2016, finds a staggering total: 9.78 billion hours.
Though numbers of that kind receive far less public attention than they should, they have helped spur significant efforts at sludge reduction at individual agencies, including the Internal Revenue Service and the Department of Transportation.
Oddly, the Trump administration has yet to comply with the law and to issue even a single ICB report. The government’s live count, compiled on a daily basis, says that on Trump’s watch, the number has exploded and is up to 11.01 billion hours. The live count is likely to be accurate, but it is no substitute for the much more detailed annual report, which can run up to 300 pages.
Sludge can produce real harm. It’s not exactly ideal if poor students cannot get financial aid unless they fill out needlessly complex forms. It’s a big problem if plumbers and truck drivers cannot get occupational licenses unless they spend dozens of hours on pointless paperwork — and then have to wait six months for a response.
Sludge audits are especially important for the health care system, which is pervaded by sludge. Sometimes it turns out to be fatal.
Consider the case of opioid use. Suboxone has become the linchpin of medication for opioid use disorder (MOUD) and is now considered the gold standard for that disorder. Suboxone is a medication that combines buprenorphine and naloxone. It reduces cravings and makes overdoses, even fatal ones, far less likely.
Emergency rooms present an important opportunity. When patients overdose or just want help, they are treated and stabilized, but long-term Suboxone regimens are not routinely commenced. This life-saving approach should be the standard of care, but it has not yet become so. Why is this?
The answer is sludge. By federal law, physicians in the United States must obtain a special X Waiver in order to prescribe buprenorphine, one of the active ingredients in Suboxone. The required time and administrative burdens around obtaining the X Waiver are preventing many otherwise willing physicians from prescribing it.
An important study found that around 20 percent of patients who entered abstinence-only heroin treatment programs were dead after one year, compared with zero deaths in the MOUD group. It follows that if more physicians obtained X Waivers and offered MOUD to motivated patients known to be at high risk of relapse, many fewer would die.
Even an informal sludge audit of the process of getting an X Waiver reveals that the burdens of the process defeat many willing physicians. A lot of them pay and sign up for training sessions, but do not complete the combined eight-hour modules. Even among those who go to all of that trouble and pay the fee, some 30 percent fail to complete required post-training forms.
Many physicians are aggressively encouraging their colleagues to “get waivered.” That’s good, but a far better policy would be to remove the X Waiver requirement entirely, a notion that has gained bipartisan attention in both the House and Senate recently.
The effect of removing the X Waiver requirement would be substantial. It would make the pathway for MOUD prescription smoother for a great number of physicians who already want to do the right thing. It would save lives.
But this is just one example. Every day, nurses and doctors must deal with unnecessary and mind-numbing administrative burdens that cost a great deal of time and money and that ultimately reduce the quality of care.
The larger point is that even when such burdens come from good intentions, they often do far more harm than good. Even informal sludge audits, based on experience and common sense, can spur reform from the private and public sectors alike. More formal efforts, producing quantitative measures of hours spent and money lost, are even better.
The time has come to cut the sludge.
Jeremy Samuel Faust is an instructor at Harvard Medical School and a physician in the Brigham and Women’s Hospital Department of Emergency Medicine in the Division of Health Policy and Public Health. Cass R. Sunstein is Robert Walmsley University Professor at Harvard.