Behavioral Economics and Health

Behavioral Economics and Health

Congressional Staff BriefingApril 12, 2013

Department of Health Department of Health Care ManagementCare Management

Center for Health Center for Health Incentives and Incentives and Behavioral Economics, Behavioral Economics, Leonard Davis Institute Leonard Davis Institute

CHERP, Philadelphia CHERP, Philadelphia VA Medical CenterVA Medical Center

University of Pennsylvania University of Pennsylvania School of MedicineSchool of Medicine

Kevin Volpp, MD, PhD

Kevin Volpp, MD, PhD – not for reproduction without permission

22

Employers report poor health habits as top challenge to maintaining affordable benefits

Source: 2012 17th Annual Towers Watson/ NBGH Employer Survey on Purchasing Value in Healthcare


33

Employers are increasingly using incentives to drive better health behaviors

Use of incentives by large employers (>1,000) 2009-13

Source: NBGH/Towers Watson 2011 Staying@ Work survey and 2012 Towers Watson/NBGH Employer Survey on Purchasing Value in Healthcare


44

Public policy also reflecting importance of incentives. . .

•Section 2705 of the Affordable Care Act allows penalties or rewards of 30-50%

• Premium adjustment may primarily result in cost shifting

Most effectively changing individual behavior likely requires behavioral economics

Source: Volpp KG, Asch DA, Galvin R, Loewenstein G. NEJM. 2011 365: 388-390,Funded by National Institute of Aging


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Making medications free is not enough to drive increased adherence

Medication Adherence

Source: Choudhry et al, NEJM 2011

• 2 RCTs among patients discharged after myocardial infarctionA. $0 CopaymentsB. Standard Copay

• Did not reduce rate of first major vascular event or revascularization


66

Drive engagement by using decision errors to help people ($≠$≠$)

Loewenstein, G., Brennan, T. and Volpp, K. (2007). Protecting People from Themselves: Using Decision Errors to Help People Improve Their Health. JAMA. 298(20), 2415-2417; Volpp, Pauly, Loewenstein, Bangsberg, (2009) Pay for Performance for Patients. Health Affairs 28(1): 206-14

Funding from Veterans Administration, CDC, Commonwealth of PA, NIMH, NIAAA,

Doris Duke Foundation


77

Tied payments are effective: Long-term smoking cessation rates triple in incentive group

Volpp, Troxel, Pauly, Asch, Galvin et al, New England Journal of Medicine. 2009; 360(7): 699-709.

p-value for difference <0.0001

Quit rates at 12 Months

• 878 Subjects from 85 General Electric worksites throughout US

• 2-arm Randomized controlled trial • Information about cessation programs • Information plus incentives worth $750

• Eligibility tied to quitting within first 6 months

• Quit rate ratio • 2.9 at 12 months (14.7% vs. 5.0%) • 2.6 at 18 months (9.4% vs. 3.6%)

• GE implemented nationwide plan in 2010 with 152,000 employees

Funding from CDC


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Rates of non-adherence to warfarin significantly lower using daily lottery-based incentives

Volpp, Loewenstein, Doshi, Troxel, Kimmel, BMC Health Service Research 2008

Level of non- adherence under lotteries compared to historic controls

Percent incorrect

doses

• Warfarin: anti-stroke medication with large benefits but high non-adherence rates

• Designed lottery – 1 in 5 or 2 in 5 chance of

winning $10 a day– 1 in 100 chance of

winning $100 each day IF took warfarin previous day

Funding from NHLBI/NIH

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Lotteries and deposit contracts both effective in achieving initial weight loss

Control Lottery Deposit contract

Volpp, KG, Troxel AB, Norton, Fassbender, Loewenstein JAMA 2008;300:2631-2637

Funding by NIA, NICHD, USDA, Hewlett Foundation

Mean weight loss by condition after 16 weeks Pounds

About 50% reached goal in intervention arms compared to 10% in control group


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Competition between individuals can augment individual motivation to increase weight loss

Mean weight loss

pounds

Kullgren J, Troxel AB, Loewenstein G, Norton L, Volpp KG. 2013 Annals of Internal medicine

Funding by National Institute of Aging

Mean Cumulative Weight Change by Month during 24-Week Intervention

Period


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Social incentives an important alternative . . .

6 month Randomized Control Trial study

•Control – usual care

•Peer mentor – talk at least weekly

•Incentives - $100 to drop one point; $200 to drop two points or achieve HbA1c of 6.5%

Long JA, Jahnle E, Loewenstein G, Richardson D, Volpp KG. Annals of Internal Medicine. 2012.

Mean change in HbA1c

Funding by National Institute of Aging


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Hovering is a key ingredient for population-based financing (ACOs, medical homes) to succeed. . .

Typical Americans may spend 1-2 hours a year with a doctor

They spend their remaining 5,000+ waking hours elsewhere

Physicians don’t know much about what patients are doing during these 5,000 hours – nor do they have effective tools to affect their behavior (e.g. medication adherence, obesity)

Proliferation of wireless technologies and advance in understanding of behavioral economics create new opportunities to improve population health

Health engagement requires a substantial amount of “hovering.”

Asch DA, Muller R, Volpp KG. 2012. NEJM

Funding by National Institute of Aging, VA HSR&D


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Applying behavioral economics increases engagement with wireless devices and applications

Participant “passively” takes medication, uses scale, pedometer etc.

Device automatically transmits information to server

Program captures behavior and calculates incentive. Transmits communication to participant

Funds electronically transferred to participant

Data CaptureData Capture Data Transmission

Data Transmission

Rewards Communication

Rewards Communication

Funds Fulfillment

Funds Fulfillment

Funded by National Institute of Aging RC2 AG036592-01 (Asch and Volpp PIs)


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Regret contest incentives are effective at improving daily device use and improving glycemic control

Sen A, Sewell T, Bellamy S et al 2013 under review

Mean change in HbA1c

3 months

Monthly Adherence Rate

Funded by National Institute of Aging


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Automated hovering solutions being tested. . .

• Smoking cessation (CVS Caremark employees) – NCI/NIH

• Obesity - Group incentives, deposit contracts, premium adjustments vs. lotteries (CHOP, Horizon, UPHS employees) – NIA/NIH, Horizon, Mckinsey, UPHS

• Potential medical home 2.0 initiatives:– Glycemic control through remote monitoring (UPHS) – NIA/NIH– Peer mentoring (UPHS diabetic patients) – NIDDK/NIH– CPAP use (UPHS, Lankenau) – NIA/NIH

• Medication adherence

– Patient vs. Provider incentives for high-risk cardiac patients (UPHS, Geisinger, Harvard Vanguard Medical Associates) – NIA/NIH

– Automated hovering post-AMI (UPHS, Aetna, Horizon BCBS, Independence BCBS, Keystone Mercy, HealthFirst, CVS-C) – CMMI/CMS

– Habit formation for medication adherence (CVS Caremark) – NIA/NIH

– Social incentives (CVS Caremark) – CMMI/CMS


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RC4 – Bring behavioral economics into Physician P4P (Volpp, Asch, Stewart, Loewenstein, Rosenthal, Sequist)

–New study at Penn/Geisinger/HVMA:• Target patients with very high risk of cardiovascular disease (>20% over next 10 years) or known CAD and who have LDL>120 or moderately high risk and LDL>140 and no contraindications for statins

• 1st study to test provider vs. patient incentives

• Addresses several limitations to P4P– Reward improvement or attainment of single threshold– Align incentives for physicians and patients– Give providers feedback on patient daily adherence– Unbundled payments

Funded by National Institute of Aging RC4AG039114 (Asch/Volpp PIs)


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CMMI project: Automated hovering post-AMI(Volpp, Asch, Terwiesch, Troxel, Mehta)

Funded by CMMI/CMS


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New Model of Automated Hovering 1.0

Funded by CMMI/CMS


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Promising future directions. . .

• Employers, insurers, pharmacy benefit managers, consumer product companies are starting to use behavioral insights to improve program effectiveness

• Behavioral economics can help improve efficiency of resources already being spent on incentives

• Population-based financing will help bring about significant opportunities for improvement in quality and cost of chronic care management using technology and social science engagement strategies


2020

Questions?

Email: [email protected]

Research: chibe.upenn.edu

Behavioral Economics and Health

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