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Behavioral Economics and Health

Behavioral Economics and Health. Congressional Staff Briefing April 12, 2013. Kevin Volpp, MD, PhD. Department of Health Care Management. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute. University of Pennsylvania School of Medicine.

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Behavioral Economics and Health

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  1. Behavioral Economics and Health Congressional Staff Briefing April 12, 2013 Kevin Volpp, MD, PhD Department of Health Care Management Center for Health Incentives and Behavioral Economics, Leonard Davis Institute University of Pennsylvania School of Medicine CHERP, Philadelphia VA Medical Center

  2. 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

  3. 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

  4. 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 Public policy also reflecting importance of incentives. . . Source: Volpp KG, Asch DA, Galvin R, Loewenstein G. NEJM. 2011 365: 388-390, Funded by National Institute of Aging

  5. Making medications free is not enough to drive increased adherence Medication Adherence • 2 RCTs among patients discharged after myocardial infarction • A. $0 Copayments • B. Standard Copay • Did not reduce  rate of first major vascular event or revascularization Source: Choudhry et al, NEJM 2011

  6. 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

  7. Tied payments are effective: Long-term smoking cessation rates triple in incentive group • 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 Quit rates at 12 Months p-value for difference <0.0001 Volpp, Troxel, Pauly, Asch, Galvin et al, New England Journal of Medicine. 2009; 360(7): 699-709. Funding from CDC

  8. Rates of non-adherence to warfarin significantly lower using daily lottery-based incentives Level of non- adherence under lotteries compared to historic controls • 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 Percent incorrect doses Volpp, Loewenstein, Doshi, Troxel, Kimmel, BMC Health Service Research 2008 Funding from NHLBI/NIH

  9. Lotteries and deposit contracts both effective in achieving initial weight loss 14.0 Mean weight loss by condition after 16 weeks Pounds Control Lottery Deposit contract About 50% reached goal in intervention arms compared to 10% in control group Volpp, KG, Troxel AB, Norton, Fassbender, Loewenstein JAMA 2008;300:2631-2637 Funding by NIA, NICHD, USDA, Hewlett Foundation 8

  10. Competition between individuals can augment individual motivation to increase weight loss Mean weight loss pounds Mean Cumulative Weight Change by Month during 24-Week Intervention Period Kullgren J, Troxel AB, Loewenstein G, Norton L, Volpp KG. 2013 Annals of Internal medicine Funding by National Institute of Aging

  11. Social incentives an important alternative . . . Mean change in HbA1c • 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. Funding by National Institute of Aging

  12. 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

  13. Applying behavioral economics increases engagement with wireless devices and applications Data Transmission Rewards Communication Funds Fulfillment Data Capture 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 Funded by National Institute of Aging RC2 AG036592-01 (Asch and Volpp PIs)

  14. Regret contest incentives are effective at improving daily device use and improving glycemic control Monthly Adherence Rate Mean change in HbA1c 3 months Sen A, Sewell T, Bellamy S et al 2013 under review Funded by National Institute of Aging

  15. 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

  16. 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)

  17. CMMI project: Automated hovering post-AMI(Volpp, Asch, Terwiesch, Troxel, Mehta) Funded by CMMI/CMS

  18. New Model of Automated Hovering 1.0 • Provision of wireless pill bottles for cardiovascular meds • Engagement incentives with daily lotteries conditional on medication adherence • Social incentive - Friend or family member enlisted for support (with automated alerts for missed pills) • Assignment of an engagement advisor at the time of enrollment (with much lower personnel ratios than in technology-based models) • Will provide evidence on how to reduce readmissions/ more efficiently manage chronic disease among high-risk patients Funded by CMMI/CMS

  19. 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

  20. Questions? • Email: volpp70@wharton.upenn.edu • Research: • chibe.upenn.edu

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