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Tag: Wellness

Eight Bright New Ideas From Behavioral Economists That Could Help You Get Healthy.

Through a series of small grants, we’re is exploring the utility of applying behavioral economic principles to perplexing health and health care problems—everything from getting seniors to walk more to forgoing low-value health care.

At a recent meeting in Philadelphia we challenged grantees to compete in an Innovation Tournament. The goal was to identify testable ideas that leverage behavioral economic principles to help make people healthier by working with commercial entities. Participants were assigned to groups and made their best pitches to their colleagues. And of course we used a behavioral economics principle (financial incentives) to increase participation: Each member of the first, second and third place teams received Amazon gift cards.

Eight teams made the finals:

1.     Love Lock: This team addressed the issue of driving and texting by proposing an app that could be installed on your cell phone that would send reminders not to text while driving. This team would work with car insurance and mobile phone carrier companies and provide discounts to those who get it installed. The behavioral economics principles being tested are default choice and opt-out.

2.     McQuick & Fit: Too many people eat unhealthy food. This team’s idea was to have a rewards card that can only be used to purchase healthy food. With each purchase, the customer would earn points toward free, healthy foods. Online orders would be placed through a website that would feature salient labeling and allow for defaults to order healthy meals. The behavioral economics principles at play include pre-commitment, default choice, labeling, and incentives.

3.     Just Bring Me Water: The problem tackled by this team is “regrettable” calories—mindlessly consuming whatever is put in front of you, such as free bread at a restaurant, or soda on a plane. The innovation: when booking a table online or calling for a reservation, you could ask to “opt-out” of the complimentary bread or chips that are offered. This would reduce the consumption of regrettable calories.

4.     Lunch Club: This group looked at addressing gluttony through a partnership with a chain restaurant. When going out for a meal, portions are typically bigger and diners consume more. But what if you had the option of doggy-bagging one third of the meal for another meal—framed as “buy dinner and get lunch free”? And, if you took this option, you would get a scratch off as an enhanced incentive and immediate reward. The behavioral economic principles being tested here include loss aversion, active choice, and incentives.

5.     Snooze, But Don’t Lose: People don’t get enough good sleep, which leads to poor executive functioning and safety issues. To increase safety, productivity, and efficiency, this group proposed using a Fitbit to build in reminders to go to bed earlier and provide feedback on good sleep. The behavioral economic principles at play are pre-commitment and loss aversion.

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Healthism: The New Puritanism

Here is a thought experiment. Assume that every hour you run you extend your life by an hour.

I have chosen a one-to-one ratio between the increase in longevity from running and the time running because higher ratios lead to the immortality paradox. Lazarus aside, the all-cause mortality for Homo sapiens is 100 % and will remain so for the foreseeable future.

This arithmetic means that at one point you will literally be running for your life: your life being extended precisely by the time spent running. But ignore this logical fallacy.

You run an hour every day for 40 years. Your life is extended by 1.67 years. Your costs are a new pair of running shoes every three months, which might even be covered at zero co-payment by insurance if USPSTF gave running a grade A or B recommendation.

A back of the envelope calculation, assuming the shoes cost $ 80, yields cost per life year of roughly $7664. There is, of course, more nuance. I am not including injuries that may result from running. I am not discounting time: I am assuming we value an hour now the same as an hour 40 years from now.

I am also not factoring the costs avoided of treating late stage cardiovascular disease, which must be balanced against the additional social security checks that the individual will draw because of living longer, not to mention the costs of treating diseases of extended longevity such as cognitive impairment, Alzheimer’s disease, recurrent falls.

But please continue to indulge my approximation. The point is not precision of economic calculations but a principle.

$7664 for an additional life year. Compared to the benchmark of $50, 000 per quality-adjusted life year that’s a bargain!

Was it worth it then?

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Are Smokers Really the ACA’s Biggest Losers?

Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers.  Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.

On November 25, Fox News put it best:  “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.”   THCB itself has headlined:  Smokers Face Tough New Rules under Obamacare.

And these headlines are absolutely accurate —  meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.

Here is how we arrive at this conclusion.  The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do.  None of the data shows that their costs are lower, but let’s say there is no impact on health spending.

Nonetheless, the following is incontrovertible:  smokers take smoking breaks.

Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them.   But we all observe these breaks, and about a fifth of us participate in them.  They reduce productivity.  By definition, if you are outside smoking, you are not inside working.

Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do.  That should give you an understanding of the impact of smoking breaks on productivity.

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The FDA Ban on Trans Fat Should Be Just the Beginning

It’s been clear for more than a decade that trans fat is a dangerous substance that increases the risk of heart disease.  Denmark banned its use in 2003.  Several American cities and states have followed suit, but the use of trans fat is still widespread despite the availability of suitable substitutes.

Over the past 10 years, trans fat consumption is thought to have contributed to an estimated 70,000 needless American deaths. Given  that universal, voluntary cooperation to eliminate trans fat hasn’t happened, the Food and Drug Administration (FDA) is justifiably seeking to designate trans fats as unsafe.

A nationwide ban on artery-clogging artificial trans fat is a long-overdue first step toward improving American diets, fighting obesity and limiting the risk of chronic disease. But it is just the first step in what should be a far broader campaign to help consumers make healthier choices at mealtime.

Public lack of awareness of the impact of prepared foods on individual health is not limited to trans fat.   When dining out, even in establishments that avoid trans fats in preparing food, Americans face a range of health risks often without realizing it. People are routinely served far more calories than they can burn.

They are routinely served too many low nutrient foods and insufficient quantities of fruits, vegetables, and whole grains.  What should become routine instead is the availability of menu options that put people’s health first.

Hopefully, the FDA’s trans fat initiative will succeed – previous city/state bans and labeling improvements have already managed to cut daily consumption by Americans from 4.6 grams in 2006 to 1 gram in 2012 – and pave the way for the creation of other standards and regulations regarding the quantity and quality of food that is offered to diners in restaurants.

The lack of such standards makes it difficult, if not impossible, for most people to recognize when they are being put at risk for a chronic disease.   If people are served too much of something (like calories), they would have to compensate by eating less later; conversely, if they are served too little of something (like vegetables), they would have to eat more later to neutralize the risk of chronic disease.

But most people lack the information they need to judge or track the quantity and quality of the nutrients they consume.

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CIGNA and Me

I have a challenge for CIGNA CEO David Cordani.  Sometime this week, pick up the phone and be a secret shopper.  Call your customer service team and ask them the same thing I asked them on a Friday not long ago: does my plan cover and reimburse for flu shots, and at which participating providers in my area?  This is managed care and wellness 101.  Just not at CIGNA.

Customer service rep A says shots are covered and reimbursed, but she cannot confirm any place in St. Louis as a par provider that would bill the plan directly for payment.  Her stubborn refusal to grasp the meaning of “par provider” was infuriating.  She repeatedly reads a list of potential providers (all national companies, such as Walgreens) and then tells me I must call each location to discern its billing practices.

Wrong.  Just plainly and simply wrong because they’re all signed to national contracts.  Then, while both my German Shepherds headed for cover in another room, she hung up on me.  (I was angry but never profane or malevolent.)

Undaunted and now even more frustrated, I call customer service again.  Customer service rep B says: shots covered fully and each location noted previously is a par provider that will accept assignment.  Done, right?  Not yet.  Customer service rep A calls me back.

She has not, however, learned anything in the intervening 15 minutes, as she returns to her home base of ignorance with the accuracy of a GPS.  Finally, I demand a supervisor.  With the supervisor comes enlightenment and lower blood pressure.

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My Personal Affordable Care Act–A Manifesto

The Founding Fathers had one.  Karl Marx had one.  Bertrand Russell and Albert Einstein had one.  And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.

This is my Personal Affordable Care Act.

My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic.  My goal is to make myself and my family as scarce as possible within the health care system.

The ACA is a collective solution to the mass failure of individual will.  Our transformation into an information culture actually worsened the malady.  We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.

First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will.  Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.

Second, despite revolutionary democratization of medical information, we still don’t do our homework.  Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.”  Really?  You need to go to the doctor for a cough?  Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.

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Confessions of a Self-Tracker


Hello.  I am Mike Painter, and I track. I don’t necessarily have a compelling reason to track health parameters such as exercise patterns, heart rate, weight, diet and the occasional blood pressure. Yet I do.  I do most of my tracking with several small devices, simple sensors and software applications. My tracking is also pretty social—meaning I share much of my data widely and daily. You’re welcome to see it—most of it is on Strava. Admittedly, I still keep some data daily on a paper calendar, and I do monitor diet and sleep in my head—i.e., nobody needs to remind me about my food splurge days. The local bakery is intimately aware of that data point as the employees witness me charge in, wild-eyed and drooling for a giant cinnamon roll every Thursday morning—almost without fail.

It all feels pretty normal to me.

Here’s the rest of the story: I track to enhance athletic performance rather than monitor my health, per se, or even really my wellness. I am an avid cyclist and have tracked miles, location, accumulated elevation, heart rate and power readings and other data for years. I share that information with both cyclist colleagues I know and don’t know on Strava. That site eagerly ingests my data—and among other things, plops it into riding (and running) segment leader boards, riding heat maps—and, most importantly, in training, trend graphs like the attached. All that data is incredibly helpful to me—it empowers me by making me face the numbers—it makes my training data- and reality-based. I don’t have to guess to maximize my fitness and minimize my fatigue level in anticipation of a big event. I follow the numbers.

Is all that bad? To me, my obsession with tracking my athletic performance seems like an extension of observing data for health and wellness.

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Healthcare’s Tech Disconnect: Why Aren’t We Building the Products Patients Really Need?

Having been supported by several small business grants from the National Cancer Institute to create online interventions for cancer patients, I have been learning gradually about commercialization models to get our work out to the public. I am dismayed about the major disconnect between eHealth entrepreneurs and eHealth intervention researchers (my personal reference group).

Last year I attended Stanford Medicine X and last week I did a demo of one of our web sites at Health 2.0 in Santa Clara. Both times, I was struck by the assumption in the IT developer and consumer community that giving people realtime feedback about their health will automatically result in major positive changes in behavior, not to mention cost savings for insurers.

The Connected Patient movement seems particularly naïve to me. Psychologists have been using self-monitoring, i.e. recording behaviors such as smoking, eating, and exercise, for at least 30 years to promote behavior change. First we used paper-and-pencil diaries, but researchers like Saul Schiffman quickly adapted the first handheld computers to prompt people to record their behaviors in realtime, greatly increasing the accuracy and power of self-monitoring.

As technology has advanced, so have our means of self-monitoring. Overall, however, the technology matters far less than the procedure itself. For most people, tracking their smoking, calories, mood, or steps does change unhealthy behaviors somewhat, for a limited period of time. A small group of highly educated, motivated people is more successful in using self-monitoring to make larger, more lasting changes.

I was reminded of this last year in a seminar on tracking at Stanford Medicine X, when a concierge physician from San Francisco and several of his patients talked about being empowered to change their health by using feedback from various types of sensors. One had paid out of pocket for a continuous blood glucose monitor since his insurance would not cover the costs to use it for his Type II diabetes.

Another doggedly demanded access to the data from his cardiac defibrillator. They believed their experiences heralded a sea change in health care in the United States. I am all for empowering patients with knowledge, tracking tools, and social support.

However, if knowledge and feedback was all it took to change unhealthy behaviors, psychologists would be superfluous in the world.

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The Summer of Wellness’s Discontent

The series of unflattering articles published in Health Affairs early this year – the first unfavorable press wellness had ever received in a top tier policy journal — turned out to be a harbinger of what became the wellness industry’s summer of discontent.  Perhaps in error, the Journal of Occupational and Environmental Medicine (JOEM) also drifted into the sea of credibility on wellness early in 2013 by publishing a meta-analysis of the industry’s claims of economic success.

The analysis, by researchers at Tufts, destroys the industry mythology of respectability by noting that out of over 2,000 papers published in the world’s medical literature, only 10 (0.5%) are worth discussing and that discussion leads essentially nowhere.  Not surprisingly, like our essays here and in Health Affairs, the Tufts work has been universally ignored by the wellness true believers.

Starting with those articles, and especially over the last four months, those true believers have lost control of the dialog — starting right here with THCB, which gets credit as the first major regular source of objective news not generated by the wellness industry’s propaganda apparatus.

June brought the RAND report, our Wall Street Journal op-ed, and Cracking Health Costs.  Unlike Health Affairs, some HR administrators have actually read those publications.  These developments left them asking uncomfortable questions of an industry that hitherto had filtered the information that its customers received through the JOEM and the Journal of Health Promotion, the industry’s de facto house organs that between them in thirty years have published fewer articles concluding wellness doesn’t work (just that single meta-analysis mentioned above) than Health Affairs has in 2013 alone.

But it wasn’t until July that the wheels fell off the wellness bus, due to four self-inflicted wounds that did more to diminish the industry’s carefully cultivated albeit totally undeserved patina than anything we could have written.    Atoning for its brief foray into accuracy, JOEM published an article showing $20-million in savings for British Petroleum’s (BP) wellness program, 100 times what the vendor, Staywell, claims on its own website to be possible.

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Obesity and the AMA, Part Two

A likely unanticipated consequence of the AMA’s decision to label obesity a disease, even though their own scientific council said not to, is that this might serve as the macguffin leading to furtherance of a protected class of people.  This has serious implications not only for employment discrimination, but also for wellness programs, which often hinge vastly overblown claims of being able to help the obese who they almost universally label as “high risk” people.

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs?  A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out.  The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor.  They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns.

Further, if the employee’s physician disagrees with offered alternative, the employer and wellness vendor must provide a second alternative.  The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach.  The AMA’s decision will actually help obese people and advocates for their dignified treatment in the workplace and society start to understand that they can refuse to opt in to these insulting programs and, simultaneously, be protected from penalties.  Clearly, this is the opposite of what unsuspecting employers expect when vendors (and their own brokers) sell them these programs: more useless doctor visits, less leverage with penalties…and more employee disgruntlement.  Not just the obese will be disgruntled, but also those who have to pay the penalties because their BMI is too high to get the reward but not high enough to get a doctor’s note.

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