Smoking, obesity, diabetes…these are some of America’s most challenging and expensive health issues, and the solution may be behavioral rather than pharmacological. Behavioral interventions can go a long way in reducing America’s healthcare burden, and for this, the field of behavioral economics has a lot to say.
Dr. Kevin Volpp, who, along with Dr. Jeanne Brooks-Gunn, received the 2015 Matilda White Riley Award, studies and designs interventions for behavioral change for particularly obstinate health issues, such as smoking cessation and weight loss. In acceptance of the award, he gave a lecture at NIH) to discuss his work.
Behavioral economics for behavior change
The framework of Volpp’s research is based in behavioral economics, which posits that people are predictably irrational. He stresses that neither information alone nor standard economics models, which rely on people being perfectly rational, are enough for people to change their behavior.
Volpp illustrates the importance of defaults with a few case studies. A 2003 study found that the percentage of people who are registered as organ donors is much higher in countries where a person is presumed to be an organ donor unless they specifically opt out compared to countries in which a person is presumed not to be an organ donor and must opt in to be so. Another study showed that generic medications were prescribed at much higher rates when the default was set to the generic medication even though providers could easily have chosen the brand name medication. This has important implications for reducing health care costs and, since patients’ adherence rates are higher for generics because they can more easily afford them, it also affects health outcomes.
The power of incentives: smoking cessation success!
Although approximately 70 percent of smokers in the US say they want to quit, only about 3% annually are able to do so. Behavioral economics goes a long way in explaining why: the costs of trying to quit are both large and immediate, while the benefits seem too distant to be a good motivator.
But behavioral economics also suggests how to design incentive programs to help. In 2009, Volpp’s team designed a smoking cessation program for General Electric that incorporated immediate incentives. This program tripled smoking cessation rates from around 5% to 15% and was so successful in its pilot run that GE expanded it to all of its employees.
Volpp modified this program in his later work with a CVS employer-sponsored program, building on his belief that people’s inherent risk aversion could form the basis for an even more successful program. In an initial study, he found that while acceptance rates were low among people offered a chance to participate in the program by using their own money as a deposit, the smoking cessation numbers were as high as 52%. This was much higher than the smoking cessation rates of people who were offered only a reward without risking their own money. To increase employee acceptance rates into the deposit program, CVS lowered the amount of the deposit and increased the reward/match amount, but it is too early to know how effective it was. However, Volpp says that the smoking cessation programs he’s created generally have high success rates in the long term, with people remaining non-smokers years after they quit.
Behavioral economics and a healthcare revolution
Volpp believes healthcare delivery in the US is shifting, noting the shift toward alternative payment models in which there is greater emphasis on keeping people healthy rather than reacting when they get sick. Thus, focus will on disease prevention, especially for those with foundations in behavior. With an estimated 40% of premature deaths in the US due to modifiable behavior, Volpp stresses the importance of creating effective behavioral intervention strategies.
However, he cautions that behavioral interventions can be time-intensive for providers. Thus, Volpp and his team are exploring the use of wireless technologies in their behavioral interventions. They provide patients with wireless devices, such as scales or blood pressure cuffs, which passively upload data to a server. The data is reviewed by healthcare professionals and feedback is electronically provided to the patient.
For example, with funding from the Centers for Medicare and Medicaid Services, Volpp is working on a program to increase medication adherence after a heart attack. Studies show that while medication adherence reduces mortality and morbidity, adherence can be as low as 40%. The program’s key elements are wireless pill bottles, daily lottery incentives, social incentives, and an engagement advisor. Early estimates show that the program increases adherence to 80-85%, but it is too early to determine longer term health and cost outcomes.
Volpp cautions that the wireless devices by themselves are not enough for patient compliance. In a study for glycemic control, Volpp saw a steady attrition in reporting within the group who was asked to monitor blood sugar levels and blood pressure daily. However, adherence rates were much higher in the group who was also given a lottery-based incentive. Using the devices was associated with better glycemic control since the providers could better monitor the blood sugar levels and give feedback.
Volpp’s future work is aimed at optimizing programs by exploring such variables as participants’ socioeconomic status, long term outcomes, and reward frequency and magnitude.
Check out the interview with Dr. Volpp where he describes behavioral economics.