Retrain the Brain

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A multitude of challenges in healthcare can be traced back to poor medication adherence. Patients fail to fill prescriptions, fail to take their medications, and fail to get refills. Along comes Wellth, a health tech company that is betting that medication adherence starts with rewiring our brains using smart incentive programs. In other words, they’ll pay you to take your pills.

Matthew Loper scooted to the edge of the couch where he sat flipping through medical research studies on his laptop and talking fast, his words jumbling together and spilling out as he tried to keep pace with his own narrative. “This one is actually fascinating,” he said, stopping at a 2010 study. “For every 100 prescriptions written, only 50 to 70 even get picked up at the pharmacy. Only 25 to 30 percent are actually taken. Only 15 to 20 percent are refilled.” He paused for effect. “This is insane to me,” he said.

Loper, who is thirty, is tall and thin with messy brown hair that seems wholly unconsidered, as if his mind has been preoccupied with something much more important. He is the co-founder and CEO of Wellth, a startup aiming to increase adherence and decrease hospital readmissions using a simple app with a reward system. It targets our inherent need for immediate gratification (a neurological predilection that usually works against us) to create and reinforce medication-craving habits. Or, more simply: he’ll pay
you to take those pills.

Wellth works like this: Patients are enrolled via their care provider and credited $150 on their Wellth app. Daily prompts cue patients to submit a photograph of their medication before they take it. This is called a “check-in.” When patients fail to check-in for the day, they lose two dollars from their credit. At the end of 90 days, the patient is awarded the remaining balance on a gift card. “The largest driver of patient readmission’s is that patients just don’t do what they’re supposed to when they leave,” he said. Take heart attack patients. He referred to another study. “By month three, less than half of those patients are still taking the medications they were prescribed at the time of discharge,” he said. Also by month three, 34 percent of them will be readmitted to the hospital.

Treatment for chronic diseases make up as much as 86% of U.S. health care expenditures. But only 50 percent of patients suffering from a chronic illness will ever complete their therapy. Nonadherence alone costs us more than $100 billion annually. And, since the 2012 launch of the Affordable Care Act’s Hospital Readmission and Reductions Program (HRRP), excessive readmissions of certain patients have resulted in many hospitals paying steep financial penalties. Mount Sinai Hospital in New York, for example, with whom Wellth will soon launch their second pilot study, is facing more than $1 million in penalties for fiscal year 2017.

Of the chronic diseases Wellth is currently targeting – heart failure, heart attack, chronic obstructive pulmonary disease, and type 2 diabetes – readmissions are penalized in all but diabetes. Loper walked me through research revealing why. These chronic diseases demanded the most healthcare dollars; medication adherence has been proven problematic in each; and if adherence were improved and readmission’s reduced, these diseases would most quickly impact a hospital’s bottom line. And, perhaps most importantly, these diseases all had actionable behaviors that could be verified, and thus incentivized, using a smartphone.

But Wellth isn’t a med-tech company, or even a tech company, Loper said. He was adamant: Wellth is a behavioral economics company. Technology alone won’t solve our medication adherence problem — many have already tried that route: lights on pill boxes, microchips on the bottles, chips in the pills. We’ve also tried patient education, pamphlets in hospitals, pamphlets mailed directly to the home, text message alerts, call center follow-ups, counseling and coaching sessions with physicians and pharmacists, and home visits from patient educators and care managers. Just to name a few. Research has shown us that humans are irrational, Loper said, but we’re irrational in predictable ways. “That’s the whole imbalance we’re trying to overcome in human psychology,” he said.

Paying people to take their medications is, at a high level, a simple concept. But there’s also a nuance to it if you want to inspire long-term behavior change. “To actually get habit formation, you have to get so much right,” he said. “If you don’t have the right incentive structure, if you don’t have the right dollar amount, if you don’t have the right interface, if it’s tedious or frustrating or doesn’t work well, people will just stop using it.”

Wellth’s structure leverages the idea of “loss aversion,” a concept formed by Daniel Kahneman and Amos Tversky, psychologists whose attempts to understand the way we make decisions, take risks, and interpret probabilities gave us our modern understanding of behavioral economics. Their theories were first published in a defining paper, “Prospect Theory: An Analysis of Decision Under Risk,” in 1979.

Tversky died in 1996 and, in 2002, Kahneman was awarded a Nobel Prize in economic science for the work. In his more recent book, Thinking Fast and Slow (a much more accessible explanation of Prospect Theory), Kahneman unpacks loss aversion and demonstrates the psychological weight of loss by inviting the reader to consider a series of propositions. For example: You are offered a gamble on the toss of a coin. If the coin shows tails, you lose $100. If the coin shows heads, you win $150. Is this gamble attractive? Would you accept it?

“Although the expected value of the gamble is obviously positive…you probably dislike it — most people do,” Kahneman writes. But if the amount you stood to gain were to increase, your good opinion of the gamble would increase with it. On average, our “loss aversion ratio” ranges between 1.5 and 2.5, which means potential loss has twice the weight of potential gain.

Dr. Kevin Volpp, a professor at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, and director of Penn’s Center for Health Incentives and Behavioral Economics (CHIBE), is leading the adoption of strategies and concepts from behavioral economics into health care and health policy. In 2008, CHIBE published their first study testing the potential for a lottery system to incentivize medication adherence. Every day that patients took their pills (Warfarin in this case), they were entered into a lottery with a 10 to 20 percent chance of winning ten dollars and a one percent chance of winning one hundred dollars. Between two pilot groups, incorrect Warfarin doses dropped from 22 percent to 2.3 percent and 1.6 percent.

CHIBE has also studied the prodding potential of other structures in various applications. Reminder devices like specialty pill boxes didn’t work. Straightforward financial rewards had little success in encouraging weight loss and helping participants to quit smoking. Lotteries were productive in both motivating weight loss (50 percent of patients lost 16 pounds in 16 weeks) and adherence to home health monitoring devices (71 percent). Loss aversion, in which the participants wagered their own money, proved successful in two weight loss studies (47.1 percent and 41.2 percent success rates).

In another CHIBE study Loper referenced showed a greater impact from loss aversion than from financial incentives. Participants were asked to walk 7,000 steps per day. The traditional financial incentive and lottery incentive groups barely outperformed the group that saw no incentives, while the group walking every day to avoid losing $1.40 from an initial credit proved nearly 30 percent more adherent.

Loper spent Wellth’s first years researching behavioral economics, patient motivations, and various incentive structures with Mike Fuccillo, Wellth’s chief scientific officer. Once the research proved solid, Alec Zopf, Wellth’s co-founder and chief technology officer, and Mark Loper, who is head of design, began building the technology platform to support and leverage the concepts. “You have to do things in a very measured and rational way,” he said. “You can’t just move fast and break things. The stakes are very high in healthcare.”

It was on the strength of this early research, in 2014 and 2015, that Wellth secured their first outside investments and launched their first pilot study with a large national health insurer (marketing restrictions bar them from releasing the name). In May, they closed a $2 million round of seed funding, which is helping to fund two more randomized controlled trials at two prominent academic medical centers, and in June, Wellth and Mount Sinai Hospital were jointly awarded a $24,500 grant from the New York City Economic Development Corporation to fund their pilot study.

When Loper, Zopf, and Fuccillo presented to Mount Sinai earlier this year, their pitch deck highlighted the hospital’s 25% readmission rate for heart failure patients. They projected the readmissions onto an entire year, tracking the rate along the same curve as the national average. After 90 days, the data showed, Mount Sinai could be looking at 40% readmissions for this patient population. After 365 days, readmissions could reach 65%. The next slide showed Mount Sinai’s projected return on investment using Wellth and estimated an annual savings of more than $1.3 million in heart failure patients alone. The patient population that will see the intervention is still being decided.

“I see the revisits, I see the problem firsthand and it is frustrating,” said Dr. Nicholas Genes, an emergency physician at Mount Sinai who is also board certified in clinical informatics and is involved in a hospital initiative to use patient generated health data to improve outcomes and adherence. Patients will leave the hospital after being stabilized and seeing their health restored, and then physicians will see them in the emergency room again one week later. In some patients, he said, it’s clear that there are dietary indiscretions and lack of adherence. It’s a complex problem for a large hospital system like Mount Sinai (which has six emergency departments all facing the same issues), and it’s a complex problem for patients, who, he said, are clearly just as frustrated when they find themselves in the emergency department.

“You know, we’re all human. You can totally understand it when you’re sitting in the hospital,” said Dr. Genes. “’I’m not going to take another drink. I’m not going to take another smoke. I’m going to take all my pills.’ Anything to get out of here and not come back. But then you start taking these pills and they don’t make you feel any different. They’re not tasty. You don’t see the effect day after day. You’re investing in an abstract future. That’s why I think Wellth has a great strategy, because they’re rewarding explicitly what you might not feel implicitly.”

Intrinsic motivators – I want to be healthy because I love my family – sometimes need a nudge from an extrinsic motivator – I want $150. Layering these motivators is essential for long-term habit formation, Loper said. The third version of the Wellth app, which is expected to launch later this year, integrates video clips of encouragement messaged from family and friends that can be unlocked after a successful series of check-ins.

“I’m hopeful that the psychological tools are catching up with the technological tools and the combination is going to succeed where education and well wishes have failed,” Genes said. However, he said, Wellth, nor any other technology, will singlehandedly resolve our issues with adherence and the resulting readmissions. “I love technology,” he said. “But it’s not a silver bullet.” Care team interventions might not always have access to a patient and, yes, they might be expensive, but they’ll continue to have a valuable role to play. “Does the Wellth intervention, on top of all the other stuff, actually improve adherence?” he said. That’s what they would study at Mount Sinai. “These are still patients that are going to have trouble filling their scripts, they’re going to have trouble getting transportation to an appointment, they’re going to have trouble paying their bills.” Mount Sinai is still implementing best practices, still actively looking for solutions, Genes said. And the problem, really, is that we’re complicated beings. “You really have to take into account the human factors,” Genes said. “It’s an art.”

One of the defining aspects of human nature is our irrationality, our inherent bias for whatever is right here and right now, the potentially self-sabotaging pursuit of immediate gratification. But if we can find patterns in this behavior, predictability within the irrationality, maybe we can create solutions that begin to “move the needle,” as Loper said. In April, he wrote a vision-casting email to his team. What if they were able to increase efficiency by just a few percentage points? He linked to a study from a Harvard economist: “A firm that was able to reduce the overuse of care by even a quarter would save the health system $330 billion annually,” he quoted. For now, though, he sees Wellth’s impact on a more human scale. “We wake up every day and we see the majority of our patients taking their pills and we know, without us, half of them wouldn’t,” he said. “That’s literally dozens of lives we’ll save this year.” By the end of next year, maybe they’ll be saving thousands or tens of thousands of people’s lives. “I truly believe we have the best approach to solving this problem,” he said. “There are literally millions of patients out there who would benefit from it. My goal is to help as many of those patients as possible.”

 

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