by Mike Miesen –
You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.
Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.
Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.
When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?
To be thorough and appropriately critical, let’s go with the following definition: a wellness program “works” if it improves the health of a population and reduces health care costs for that population. Full stop.
Unsurprisingly, this high bar doesn’t leave room for a lot of success. One of the Health Affairs studies found a 12% reduction in hospitalizations and a $22.20 per member per month decrease in inpatient health claims cost – but also a $19 per member per month increase in non-inpatient claims costs (which doesn’t include the wellness program costs, which were substantial). Clearly, it’s a good thing that patients are spending less time and money in hospitals – something we should celebrate! – but without the resulting decrease in costs, this doesn’t fit our definition of “working.”
Another found that Florida’s, Idaho’s, and West Virginia’s wellness incentive programs for Medicaid members were unsuccessful at engaging the population. Two shocking stats from the study: of Florida’s entire Medicaid population, from early 2006 to July 2011, “only two enrollees earned credits for participating in a smoking cessation program…” and “only two enrollees earned credits for participation in an exercise program.” These programs utterly failed to engage their patient populations in a meaningful way.
So, what’s going on? Are all wellness programs doomed to fail?
Maybe, but I am much more bullish on their prospects. First, let’s concede that “wellness program” is an overly-broad umbrella term that includes everything from “Hey employee, here’s $20, go join a gym” to the most sophisticated, targeted interventions; the failure of one wellness program says little-to-nothing about whether another program will succeed. It’s also instructive to remember that many of these studies started in 2005, which, in technological terms, was a lifetime ago (need proof? Check this out)—and there are reasons to believe that technology may be a missing link in making wellness work.
What else may help us crack the code? Drawing on behavioral economics and networking theory, the following components hold promise:
Turn Wellness Into a Game: Provide Feedback Instantly. A recent Wall Street Journal article discussed popular consumer items like the Jawbone UP and Nike FuelBand – essentially, tricked-out pedometers. It’s a bit fawning, but cites a JAMA study in which people with pedometers took an average of 2,491 more steps per day (almost an extra half hour of walking). Make walking a game, and people walk more.
This result also gels with what Daniel Kahneman and other behavioral economists have shown: hyperbolic discounting – our tendency to value immediate incentives more than future incentives – is a significant cognitive bias. We’re primed to care about now before we care about later; we’re biased to the present. Taking advantage of this bias in the form of instant feedback, as in the immediate reward of knowing how many steps you’ve just taken, can be a mechanism towards making wellness work. This is, more or less, why many believe gamification holds such promise.
Take Advantage of Automated Hovering. It’d be creepy if your doctor or nurse practitioner spent all day, every day, with you, clipboard in hand. With devices like Asthmapolis (an asthma inhaler add-on that connects with your smartphone via Bluetooth to track your inhaler use), he or she doesn’t have to; if you use your inhaler frequently – a sign that your disease isn’t well-controlled and that you’re at high-risk for a run-in with your local Emergency Department – your physician automatically gets a warning, no physical hovering necessary.
This is only one example of what Professor Kevin Volpp has termed “automated hovering” – essentially, passive data collection via available technology. As sensor costs fall and smartphone adoption rises, automatic, passive monitoring will become an increasingly important tool to improve the health of a population.
Emphasize Social Connection. The pedometer article cited above ends with this quote: “It’s like a videogame. I have such a competitive personality, so I’m going to beat these people today.” Which gets at a fundamental truth: we are social animals, and our motivations are inextricably linked to our interactions with others. Nicholas Christakis and James Fowler showed that health behaviors can be contagious; as someone who runs and works out regularly, I improve the chance that my friends – and, interestingly, their friends, even if I don’t know them – become marginally healthier.
Connecting with others to get healthy and stay healthy is as easy now as logging onto a social network. at the vanguard of this trend are companies like CafeWell, Keas, and RedBrick – social networks to get healthy and stay healthy. The challenge, as ever, is to make these networks as addicting as Facebook, so that patients stay interested and engaged in their health.
To be sure, it’s not immediately clear that a wellness program that included all of those components would work, in our sense – while they can all scale considerably, they aren’t cheap to start. And it’s pretty easy to be unhealthy, or to forget to take your medication. But, if I had my wellness druthers, that’s where I would start to make wellness work.
Mike is a healthcare consultant currently on loan to the Ugandan Ministry of Health (through a NGO), leading a project to reduce maternal mortality. Follow him on Twitter @MikeMiesen or subscribe to the blog.