Five thousand hours. That’s how long the average person spends each year awake and not in front of a doctor. People tend to think of health care as the time you spend getting checkups or going to a doctor’s office or hospital when you’re sick. The truth is your health is substantially more dependent on the time you’re not around your doctor than when you are. It’s about the choices you make during those 5,000 waking hours.
Influencing people’s lifestyles and behavior during those hours is the mission of David Asch, MD, MBA. Asch is the director of Penn’s Center for Health Care Innovation, and he recently spoke at the JP Morgan Health Care Conference in San Francisco on the challenges and innovations involved with getting a patient to follow a doctor’s advice once the office visit is over.
“Sixty percent of patients who are on beta blockers for heart disease don’t take their drugs,” Asch noted as an example.
Asch was part of a panel on the next wave of innovation in health care. Other panelists spoke about bringing data and science together to pioneer new therapies for neurological diseases like Alzheimer’s or dementia, using existing knowledge of CAR T therapy to find new targets and improve cancer treatments, or even the incredible goal of developing preventative measures – like a flu shot for cancer.
Asch was focused on health technology and human behavior. As he explored the problem of non-adherence, he noted that it’s a problem in the way people think, not in what they know.
“The dominant belief is that education leads to behavior change,” Asch said. “I’m certainly not against helping people understand how to improve their health, but experience suggests it doesn’t get you very far.”
Instead, Asch and his team – including close Penn colleague Kevin Volpp, MD, PhD, director of the Penn Center for Health Incentives and Behavioral Economics – have developed a platform called “Way to Health,” named for the 1758 essay The Way to Wealth by Pennsylvania Hospital founder Benjamin Franklin. It’s the essay that gave us famous Franklin quotes like, “Early to bed, and early to rise, makes a man healthy, wealthy, and wise.”
The “Way to Health” initiative is based on more modern insights into behavioral economics. The idea is to take all of the influences on a person’s life – from personal relationships to the technology they use – and combine them in ways to promote better lifestyle choices.
“When you have a medical circumstance in those 5,000 hours, who are you most likely to be near and reach out to?” Asch posited. “Is it going to be your doctor or nurse? Unlikely. When you’re trying to decide whether to go the gym or watch TV, it will likely be your spouse or your roommate or your friend. This is about finding ways to harness those relationships.”
Asch has authored research on the power of social relationships when it comes to medicine. What separates this program from others looking into similar questions is that Penn has the platform to automate this approach and keep it plugged into a patient’s daily routine. Smartphones and activity trackers like Fitbits are only the start. Electronic pill bottles let doctors and friends know if someone has skipped their medication for the day. Blood pressure cuffs will alert a spouse about each measurement. CPAP machines will let a family member know if a patient didn’t wear it at night to help with sleep apnea. Asch notes that while those devices help doctors monitor behaviors, they will rarely change behaviors unless paired with engagement strategies informed by behavioral science.
“Just like Facebook gives us a platform for digital relationships, 'Way to Health' can do that in a health context,” Asch said. “Imagine you’re trying to manage your blood pressure, and you’re reporting on your readings. Your friend is getting messages about whether you are in or out of control and urging you to take your medicines. For other people, this is just a concept. Penn has the platform to do this.”
The platform also combines the social inducement with a financial one, though it’s not as simple as just paying to reward people for following their doctor’s advice.
“People’s initial intuition is to just give prizes, but the deeper insight is that the design of the reward system is often more important than the amount,” Asch said.
That insight led to the creation of what Asch calls the “Regret Lottery,” a concept that drew a combination of appreciative laughter and understanding nods from the crowd listening to the JP Morgan presentation. Each patient is given a two digit number, and each day, a number is randomly selected. If a patient’s number comes up, they get $100. However, if that patient is found to be out of compliance – say for skipping their medication that day – they get a message telling them they could have won the money but didn’t because they didn’t take their pill.
“The lottery incentive is cute and funny and understandable, but the big picture is that we should stop using transactional rewards,” Asch said. “The virtue of the behavioral economic approach is that we can take the same $25, redesign how it’s delivered, and greatly improve its motivational potency.”
In addition to getting more motivation out of each dollar, Asch points out that this can also lead to equal motivation for less money. In other words, it expands what doctors can do with the money they have, which is tremendously important given the inherent challenges of funding.
Asch has brought all of this knowledge together to launch the “Nudge Unit” at Penn – a program directed by Mitesh Patel, MD, MBA, an assistant professor of Medicine and Health Care Management. It’s the world’s first behavioral design team embedded within a health system. Its mission is to leverage insights from behavioral economics and psychology to design and test approaches to steer medical decision-making toward higher value and improved patient outcomes.
Research is already underway across several areas. One team is currently running a trial that uses the regret lottery in hopes of reducing readmissions for congestive heart failure patients. These patients tend to be readmitted because of excess fluid, meaning they either failed to take their medication or because they’ve eaten salty foods. Electronic pill bottles and scales flag a missed dose or weight gain and alert the patient’s cardiologist.
Other new ventures include initiatives to reduce smoking among pregnant women or help patients manage depression and anxiety. Most recently, researchers applied this approach to the opioid crisis. Studies of patients who have never been prescribed opioids have found that initial prescriptions that include a large number of tablets are associated with long-term use and more tablets leftover that can be misused or abused. In response, Penn researchers found adding a default option for a lower quantity of tablets in the electronic medical records discharge orders may help combat the issue by “nudging” physicians in emergency departments to prescribe smaller quantities. The new data informs a larger study that will involve 50 emergency departments and urgent care centers affiliated with 24 hospitals.
“Opportunities for effective nudges abound in health care because choice architectures guide our behavior whether we know it or not,” Patel, Asch, and Volpp, wrote in a perspective recently published in the New England Journal of Medicine. “Though there is some common sense involved in creating effective nudges, expertise is also required — for identifying promising targets, designing both the conceptual approach and the technical implementation, managing the politics and process of obtaining stakeholder buy-in, and evaluating impact.”
Given the value of its applications, they argue that nudges are a small investment and most health systems would be “well served” by supporting the development of internal nudge units, which have improved government policies around the world.