Newsletter October 2012

In This IssueWay to Health: The Next

Step in AutomatedHovering

Enabling Innovation: NewCenter is Created

Research Spotlight:Kathryn Saulsgiver

Translating Research IntoPractice: Benefits of

Working with CorporatePartners

Musings of a BehavioralEconomist

New Initiatives

Quick Links

About Us

LDI Health Economist

Supporting CHIBE

Contact Us

CHIBE in theNews

Remote MonitoringStudy Offers FinancialIncentives forMedication AdherenceMedCity News 9/27/12

Penn-CMU Roybal

Penn-CMU Roybal Center Retreat Attendees September 13-14, Cape May

Dear Colleague,

We are excited to report on some major new initiatives at CHIBE in our Octobernewsletter, such as our ongoing work with corporate partners and a Center forMedicare and Medicaid Innovation sponsored project to partner with theUniversity of Pennsylvania Health System, Independence Blue Cross, HorizonBlue Cross Blue Shield, Keystone Mercy, Health First, and CVS Caremark toimprove medication adherence rates. The strategy of "automated hovering" tohelp patients improve their health behaviors guides this project, and thisnewsletter presents several perspectives from those who are designing andoperationalizing this strategy in the once disparate contexts of health careprovision and academic research. This issue turns the spotlight on the research of Kathryn Saulsgiver, a CHIBEinvestigator who has been busy testing ways to help people improve their dietsat a local supermarket in West Philadelphia. David Huffman, a visitingprofessor at Penn, is the contributor in this issue to our regular column"Musings of a Behavioral Economist" and calls for a systematic approach toresearch on defaults. We hope you enjoy reading this issue. Best wishes for an enjoyable fall season! Sincerely, Kevin Volpp, Director Scott Halpern, Deputy Director

Way to Health: The Next Step in AutomatedHovering

Automated hovering, the concept of encouraging people to change unhealthy

Ralph Muller

Center Convenes inCape May for AnnualRetreatLDI Health Economist9/24/12

VALUE Framework toTeach FuturePhysicians Value-based CareAmerican Medical News9/19/12

LDI Health InsuranceExchange GroupConvenesLDI Health Economist9/14/12

Lessons for the HealthCare ProfessionHarvard Business Review9/13/12

Will the Soda TaxMake Us Healthier?Knowledge at Wharton,9/12/12

Soda Bans: NannyState or Nudge?Marketplace Money8/31/12

Way to HealthFeatured in"Healthcare StrategyAlert!"Healthcare StrategyInstitute 8/30/ 2012

The Risks ofIntentionallyUnvaccinatedStudentsPenn RN Research News8/28/12

LDI Sponsors SummerUndergraduateMinority ResearchProgrammeThe Times of India8/27/12

Warfarin AdherenceStudy Cited as CrucialHealth ResearchWall Street Journal8/10/12

behaviors through social media, wireless devices and other technologies, hasmoved to the next tier. In a recent New England Journal of Medicine article entitled "AutomatedHovering in Health Care-Watching Over the 5000 Hours," authors David Asch,MD, MBA, CHIBE member and Executive Director of the Penn Medicine Centerfor Innovation, Ralph Muller, MA, Chief Executive Officer, Universityof Pennsylvania Health System, and Kevin Volpp, MD, PhD, Director of CHIBEand the Penn-CMU Roybal P30 Center on Behavioral Economics and Health,discuss how this newest care model may offer promise. The traditional method of trying to motivate people to better health ofteninvolves some home visits or telemedicine services, which can also include aclinician. "One problem is that using personnel in hovering is expensive andtherefore difficult to scale up and to justify," they state. Enter the Way to Health, a web platform created to enable automated hovering.Developed with funding from a grant from the National Institutes ofHealth/National Institute on Aging, it is an online tool kit tosupport a more efficient way of conducting behavioral economics studies.

"We are very excited about carrying outthis demonstration," Muller says. "This is avery intriguing hypothesis." "It is incredibly cool!" says Asch. "Itprovides an organized way to connect topeople with the technology in theirpockets. It can also help us to betterunderstand how to engage with people intheir everyday lives as well as to let usreach out to people from all over thecountry." When people agree to participate in astudy that is part of the Way to Healthplatform, they receive a welcome emailwith information about what is expected

and instructions on how to participate. They also select how they would like toreceive messages--text, e-mail, or telephone--and provide their paymentpreference for receiving incentives. Then they can log onto their personaldashboard to participate in their particular study. They can also view theirnotifications and upcoming study-related events. The system is interactive. In a study to measure medication adherence, forexample, the enrollees are sent an electronic pill bottle. Each day the participanttakes a pill, the 'cap' transmits a signal to the Way to Health portal and to thestudy coordinator; this creates an objective assessment of medicationcompliance. For another study, designed to measure the success of participants trying to loseweight, participants are asked to step on an electronic scale. Upon stepping onthe scale, the participant enters a personal code and an embedded camera takesa picture. Both the photo and the participant's weight are automaticallytransmitted to the Way to Health portal by this specially equipped scale.

Drought May Lead toIncreased Prices ofNutritious FoodsToledo Blade 7/26/12

Novel Approaches toImprove HealthBehaviorsThe Incidental Economist7/7/12

Value In Health CareInstitute of Medicine7/1/12

RecentPublications

Bending the cost curvethrough market-basedincentives.Antos JR, Pauly MV,Wilensky GR. N Engl J Med. 2012;367(10):954-958.

On the Way to HealthAsch DA, Volpp KG.LDI Issue Brief. 2012;17(9).

What business are wein? The emergence ofhealth as the businessof health care.Asch DA, Volpp KG.NEJM. 2012. Epub aheadof print.

Self-interest withoutselfishness: Thehedonic benefit ofimposed self-interest.Berman JZ, Small DA.Psychol Sci. 2012. Epubahead of print. Using mHealthtechnology to enhanceself-monitoring forweight loss: Arandomized trial.Burke LE, Styn MA,Sereika SM, Conroy MB,Ye L, Glanz K, Sevick MA,Ewing LJ. Am J Prev Med. 2012;43(1): 20-26.

Some members of the Way to Health team: (back from left) Beth Stearman, KathrynSaulsgiver, Lisa Wesby, David Shuttleworth, Alex Gilbert

(front from left) Kathryn Volpicelli, David Asch, Dana Gatto, Megan Healy, Kristin Harkins,Kevin Volpp

We currently have a number of smaller scale pilot studies and five larger-scalerandomized clinical trials running on the platform," says Beth Stearman,Research Project Director at CHIBE. "All use the same core Way to Healthfunctionality with customization based on study design. At full capacity, we willbe able to run a really high volume of studies at the same time." Although the final reports aren't in yet, expectations remain positive. "Ifsuccessful, the Way to Health platform will lower the cost of this kind of work,"and, in the real-world health care settings, it could improve both the quality andefficiency of care provision, says Asch. "Automated hovering is a supplement to the personnel centered approach,"adds Muller. "It provides an important complement to what doctors and nursesdo." -Nan Myers

Enabling Innovation: New Center is Created

Recognizing that changes are needed to the healthcare landscape, and lookingfor ways to ensure that the right steps will be taken to implement them, in late2011 the University joined with the Health System to create the Penn MedicineCenter for Innovation (PMCI). Led by Executive Director David Asch, MD,MBA, along with Co-Directors KevinVolpp, MD, PhD, who is also Director of CHIBE, and Kevin Mahoney, Senior VicePresident and Chief Administrative Officerof the Health System and Vice Dean ofIntegrative Services at the Perelman Schoolof Medicine, it is also a partnershipbetween the School of Medicine and theLeonard Davis Institute. PMCI was developed specifically tofacilitate and implement innovation within

David Asch

Roy Rosin

Shivan Mehta

Increasingsupplementalnutrition assistanceprogram/electronicbenefits transfer salesat farmers' marketswith vendor-operatedwireless point-of-saleterminals.Buttenheim AM, HavassyJ, Fang M, Glyn J, KarpynAE. J Acad Nutr Diet. 2012;112(5):636-641. Health service useamong the previouslyuninsured: Issubsidized healthinsurance enough?Decker SL, Doshi JA,Knaup AE, Polsky D.Health Econ. 2012;21(10):1155-1168. Impact of cost-sharingon treatmentaugmentation inpatients withdepression.Gibson TB, Jing Y,Bagalman JE, Cao Z,Bates JA, Hebden T,Forbes RA, Doshi JA. Am J Manag Care. 2012;18(1):e15-22. Retail grocery storemarketing strategiesand obesity: Anintegrative review.Glanz K, Bader MD, IyerS.Am J Prev Med. 2012;42(5):503-512. Beneficiary orbenefactor: Are peoplemore prosocial whenthey reflect onreceiving or giving?Grant A, Dutton J.Psychol Sci. 2012;23(9):1033-1039. Shaping end-of-lifecare: Behavioraleconomics andadvance directives.Halpern SD.

the Health System and the School ofMedicine. Its mandate is to focus onimproving the patient experience,anticipating and responding to changes inhealthcare financing and identifying waysto achieve positive health outcomes foremployees, patients and the community.

By combiningthe expertiseof faculty members ofthe School ofMedicine andthe WhartonSchool, "it ishelping us to bring some of the best practices tothe Health System," explains Roy Rosin, MBA,Chief Innovation Officer for PMCI. "We know thatthe future of healthcare will be outcome- andvalue-based and that we need to engage a broad,interdisciplinary team to chart a path to adifferent way of conducting business."

"Given that we know what is coming, we have to learn how to get there," Rosinadds. To support this mission, the PMCI invited input and representatives(including students) from throughout the University and Health System toparticipate in the Innovation Center. "We found that with the more differentperspectives you bring to the table, you get a wider range of ideas." CHIBE is an integral member of PMCI. When the Center was announced, it wasnoted that members would test how insights from behavioral economics canimprove patient health and reduce the rate of healthcare costs. One of the first projects undertaken bythe Innovation Center was to look at theculture of innovation across theHealth System, explains Shivan Mehta,MD, Director of Operations for PMCI."We coordinated a 'Big Ideas' campaignwhich asked for ideas to improve thepatient experience, and opened it up tothe entire Penn Medicine staff. Our goalwas 500 responses; we received 1,739.We winnowed down the responses to themost promising ideas, which were thenescalated to facilitator-led workshopsand translated into draft business plans.The final stage involved 10 teams of finalists. We are currently working with thewinning teams to advance their ideas to implementation within the HealthSystem." (Follow this initiative's progress here.) Mehta says one of the tenets of PMCI is that "we are working with teams toevaluate ideas and research solutions. We must actually be sure that they aresolving the right problem. Throughout the process we continually measure, testand, when necessary, alter the solution. We look at the entire process. "We know that you don't just implement, you have to make sure it solves aproblem." -Nan Myers

Kathryn Saulsgiver

Semin Respir CritCare Med. 2012;33(4):393-400. Perceptions of organdonation aftercirculatorydetermination ofdeath among criticalcare physicians andnurses: A nationalsurvey.Hart JL, Kohn R, HalpernSD.Crit Care Med. 2012;40(9): 2595-2600. Measuring theprevalence ofquestionable researchpractices withincentives for truthtelling.John LK, Loewenstein G,Prelec D. Psychol Sci. 2012; 23(5):524-532.

Organ allocationpolicy and the decisionto donate.Kessler JB, Roth AE. American EconomicReview. 2012;102(5):2018-2047. Randomized trial oflottery-basedincentives to improvewarfarin adherenceKimmel SE, Troxel AB,Loewenstein G,Brensinger CM,Jaskowiak J, Doshi JA,Laskin M, Volpp K. Am Heart J. 2012; 164(2):268-74.

Novel incentive-basedapproaches toadherence.Kimmel SE, Troxel AB. Clin Trials. 2012. Epubahead of print. Effect of the MedicarePart D coverage gapon medication useamong patients withhypertension andhyperlipidemia.

Research Spotlight: Kathryn Saulsgiver While psychologist and behavioralpharmacologist Kathryn Saulsgiver wasat the University of Vermontcompleting her postdoctoral behavioralpharmacology research amongsubstance abusers, she heard a visitingKevin Volpp describe his GE smokingcessation study and decided to seek aposition at CHIBE. Saulsgiver is now aResearch Associate at the Center andleads Scott Halpern's Way to Quit R01investigation that uses the Way toHealth research platform to evaluateincentive-based behavioral economicinterventions to help people quitsmoking. Inspired by her mentorsVolpp and Halpern, Kathryn proposedand received funding for her own pilot research project, Way to Healthy Eating,a behavioral economic intervention to increase fruit and vegetable purchasingamong low-income West Philadelphia grocery shoppers. What drew you to this project? I saw parallels between substance abuse and unhealthy eating. Bothmaladaptive behaviors emerge from independent choices which, in some cases,can become self-destructive habits. Unfortunately, these types of hard-to-breakhabits are easy to establish, and the world views these habits as a choice that theindividual could easily change. For both behaviors, however, environmentalcircumstances such as price differentials and social interactions are nudgingindividuals towards these unhealthy choices. I thought that these similaritiesmight make poor eating habits amenable to behavioral economic interventions. What were you trying to achieve? Currently, grocery shoppers in a low-income West Philadelphia neighborhoodnear Penn spend less than six percent of their grocery budget on fruits andvegetables. I tried to raise that to at least fifteen percent with the Way toHealthy Eating study, which was a four-arm trial that compared informationprovision and flat and tiered incentives with no intervention. All participants,except those in the control arm, received feedback on their grocery shoppinghabits. Participants in the flat incentive arm were also reimbursed fifteenpercent of their total grocery bill if they hit the fifteen percent fruit andvegetable purchasing goal. People in the tiered incentive arm could bereimbursed fifteen, twenty or twenty-five percent of their total grocery billdepending on the percentage they spent on fruits and vegetables. How did you get the study up and running? I met and worked with Jeff Brown, the President and CEO of Brown'sSuperstores, the company that owns the ShopRite not far from Penn, where webased our research. Mr. Brown has established Uplift Solutions, a non-profitorganization dedicated to addressing limited food access, substandardeducation, inadequate safety, and unequal opportunities faced by residents of'at risk' neighborhoods. Mr. Brown allowed my research team to set up arecruiting table in his West Philadelphia ShopRite store and provided access toour participants' shopping data via the "Price Plus" shopping card program. We

Joelle Friedman

Li P, McElligott S,Bergquist H, Schwartz JS,Doshi JA. Ann Intern Med. 2012;56(11):776-784. Can behaviouraleconomics make ushealthier?Loewenstein G, Asch DA,Friedman JY, MelicharLA, Volpp KG.BMJ. 2012;344:e3482. Concepts of healthydiet among urban,low-income AfricanAmericans.Lucan SC, Barg FK,Karasz A, Palmer CS,Long JA. J Community Health.2012; 37(4):754-762. Parental decision-making preferences inthe pediatric intensivecare unit. Madrigal VN, Carroll KW,Hexem KR et al. Crit Care Med. 2012;40(10):2877-2882. Public opinion aboutfinancial incentivesfor smoking cessation.Park JD, Mitra N, AschDA.Prev Med. 2012. Epubahead of print. The New York Timesreaders' opinionsabout paying people totake their medicine.Park JD, Metlay J, AschJM, Asch DA.Health Educ Behav. 2012.Epub ahead of print. Leveraging insightsfrom behavioraleconomics to increasethe value of health-care service provision.Patel MS, Volpp KG. J Gen Intern Med. 2012.Epub ahead of print. Effectiveness ofinterventions to

used the data to determine eligibility for incentives and as the basis for feedbackand nutrition counseling. What did you learn? I learned that community-based research has its own challenges and rewards.For example, grocery shoppers in West Philadelphia may not visit the samestore twice in a month. They follow coupons and circular deals for the bestbargains. These completely rational behaviors made it difficult for my researchteam to recruit a sizable sample for the study. What is next for you? I need to be able to recruit and track participants in more than one grocerystore to effectively evaluate this intervention in low-income communities. So, inpartnership with Uplift Solutions and ShopRite, I hope to widen the scope ofthe project to include multiple stores. In the meantime, I will continue workingwith Dr. Halpern on Way to Quit and with Dr. Volpp on a demonstrationproject testing a variety of incentives for the prevention of chronic diseaseamong people receiving Medicaid in New York. -Christine Weeks

Translating Research Into Practice: Benefitsof Working with Corporate Partners Part of the CHIBE's mission is to engageprivate and public sector partners to developand test scalable and cost-effectiveapplications. This objective is part of ourmission due to the importance of translatingresearch into practice and thereby making adifference in how effective programs are inimproving health. In pursuit of achieving thisobjective, we have established severalpartnerships with a number of differentcorporations. The types of partners that wehave engaged range from large healthinsurance companies to employers andpharmaceutical benefit managementcompanies. Typically we are approached by anoutside organization that has identified one or more pressing challenges thatthey are facing. Collaboratively, we then develop and propose research projectswhich test different ways of addressing those challenges. Once an approach isagreed upon, we then embark on planning and implementation of the project,with a focus on ongoing evaluation and refinement of the programs that wedevelop. As researchers, it is always exciting to see applications of our research in thefield. Recently, we worked with a large health insurance company to develop anew insurance product. The development process included behavioral economicthought leadership around the new benefit design coupled with in-depth marketresearch. We introduced a rigorous research component into the productdevelopment cycle which was unique for this organization. As with most largeorganizations, this particular research partner rarely has the time to vet theirbenefit design assumptions with various stakeholders as they are usually sofocused on completing milestones. As a result of our expertise, the new benefitdesign is grounded in evidence-based research. In addition, the research that

David Huffman

increase screening forbreast, cervical, andcolorectal cancers:Nine updatedsystematic reviews forthe guide tocommunity preventiveservices.Sabatino SA, Lawrence B,Elder R, Mercer SL,Wilson KM, DeVinney B,Melillo S, Carvalho M,Taplin S, Bastani R, RimerBK, Vernon SW, MelvinCL, Taylor V, FernandezM, Glanz K. Am J Prev Med. 2012;43(1):97-118. Incentivising personalresponsibility:Conceptualclarification andevidence.Schmidt H. Z Evid Fortbild QualGesundhwes.2012;106(3):185-194.

Cost-effectiveness oflong-term outpatientbuprenorphine-naloxone treatmentfor opioid dependencein primary care.Schackman BR, Leff JA,Polsky D, Moore BA,Fiellin DA. J Gen Intern Med. 2012;27(6):669-676. Decision quicksand:How trivial choicessuck us in.Sela A, Berger J. J Consumer Research.2012; 39(2):360-370. A transition model forquality-of-life datawith non-ignorablenon-monotonemissing data.Liao K, Freres DR, TroxelAB. Stat Med. 2012. Epubahead of print. Medicare's newhospital value-basedpurchasing program is

we conducted also provided insights into how to market the new product topotential consumers. These types of opportunities are a huge benefit to both the corporate partnerand the Center by providing the organization with an evidence-based programthat is designed based on cutting edge research. -Joelle Friedman

Musings of a Behavioral Economist Defaults are in many ways the poster childfor the behavioral economics movement inhealth. They offer the promise of a low-costway to "nudge" people towards betterhealth, without being overly restrictive ofchoice since people can always opt out.Defaults have been shown to havesubstantial effects on outcomes in non-health and health domains, including (butnot limited to) retirement contributionrates, organ donation rates, flu vaccinationrates, advanced directive decisions, andrates of consuming fruits and vegetablesduring school lunch. At this point, however, there is still limited knowledge about why defaults work.A variety of different mechanisms have been proposed - implicitrecommendation, procrastination in opting-out, inattention, desire to minimizeregret - but the relative importance of these different channels has not beenestablished. Defaults in different settings may necessarily vary in the strength ofthese various features, and it is not known how this will impact the effectivenessof the default. For example, whether an employer or a doctor sets a defaultmight affect the perceived value of the implicit recommendation. As anotherexample, in some policy-relevant settings it may not be possible to offer adelayed opportunity to opt out, removing the procrastination "lock-in" effect; itis not clear whether defaults will be strong when lacking this feature or not. There is also growing number of published examples where defaults did notaffect behavior, or at least not in a cost-effective way. For example, when thedefault contribution for 401(k)s was increased to the relatively high level of12%, most people opted out. In another case, a default to encourage low-incometax filers to save part of their tax refund had little impact, as people almostuniversally opted out. Making a portion of fruits and vegetables the default forschool lunches increased consumption of fruit and vegetables, but also lead to amassive increase in the amount of wasted fruit and vegetables. Defaults remain a very promising lever for improving health outcomes, but thetime seems ripe for more systematic research on the mechanisms underlyingdefaults, in order to understand when defaults will be powerful and when theywill be less effective.

-David Huffman

New Initiatives Testing Behavioral Economic Interventions to Improve Statin Use

likely to have only asmall impact onhospital payments.Werner RM, Dudley RA.Health Aff. 2012;31(9):1932-1940.

Awards

Peter ReesePresidential Early CareerAward for Scientists andEngineers

Scott HalpernDepartment of MedicineAustrian Award

UpcomingEvents

Wharton DecisionProcesses Colloquia:Fall Series 201212:00-1:30pmHuntsman HallRoom 340

10/15- Michael TuanPham10/29- Thomas Gilovich11/5- Nicholas Epley11/12- Clayton Critcher11/26- Phil Fernbach12/3- Anuj Shah

LDI Post-DocRecruiting Seminarwith MichaelRichards, MD, MPH 10/12/12- 12:00-1:30PMColonial Penn CenterAuditorium

LDI/Wharton PennRisk InsuranceProgram ResearchSeminar with AmyFinkelstein, PhD10/19/12 - 12:00-1:30PMColonial Penn CenterAuditorium

LDI Research Seminar

and Reduce CVD RiskFunded by: NIH/National Institute on Aging The application of conceptual approaches from behavioral economics offersconsiderable promise in advancing health and health care. In patients withsuboptimal cholesterol control who are at high risk for CVD, this study will testthe effectiveness and cost-effectiveness of different behavioral economictechniques to improve statin adherence following discontinuation of theintervention. Investigative team leaders Iwan Barankay, Kevin Volpp and PeterReese will use a 4-arm randomized controlled trial to compare the effectivenessand cost effectiveness of alternative approaches to inducing habit formationamong CVD patients with poorly controlled cholesterol who have beenprescribed statins. Social Goals and Individual Incentives to Promote Walking in OlderAdults Funded by: The Robert Wood Johnson Foundation and the DonaghueFoundation Evidence from behavioral economics suggests that people have short timehorizons and difficulty trading off immediate for delayed health benefits. Littleis known, however, about whether financial incentives can be effective inencouraging higher levels of physical activity among older adults, particularlywhen they are in the form of social goals. The goal of this pilot randomizedcontrolled trial is to test whether a financial incentive of a donation to achieve asocial goal is more effective to motivate and sustain a daily walking habit thanthe same dollar value given to an older adult. This study, led by Karen Glanzand Jason Karlawish, will recruit adults 65 and older to use Way to Health witha digital pedometer-internet interface.

Using Behavioral Economics to Promote Medication Adherence andHabit FormationFunded by: The Robert Wood Johnson Foundation and the DonaghueFoundation Poor adherence to medication regimens is a significant problem in healthcare.This study, led by Judd Kessler, will investigate simple behavioral economicsinterventions to overcome cognitive and motivational barriers to medicationadherence. The goals of this study are to analyze which interventions are mosteffective in promoting medication adherence; to analyze which interventionsare most effective in promoting long-term habits that persist even when theinterventions are removed; and to understand how various patientcharacteristics predict adherence or treatment receptivity.

Cost Sharing Impact on Uptake and Attendance Among People in aWorkplace Weight Watchers Program Funded by: Weight Watchers, Inc An important unresolved question in the incentive literature is how to optimallyset patient cost-sharing for services that require ongoing patient engagement.Standard economic theory would suggest that lowering prices to zero (or evenbelow zero) would maximize program attendance; however, the goal of theWeight Watchers program is not attendance per se but weight loss and it ispossible that people who come to the program because it is lower cost or freewill value it less and thereby exert themselves less and be less successful inlosing weight. It is also unclear how much attendance would change withchanges in price and whether the increased attendance would be worth the costof the subsidies. This study, led by Kevin Volpp and Leslie John, will test the

with Nicole Maestas,PhD 10/26/12 - 12:00-1:30PMColonial Penn CenterAuditorium

LDI Health PolicySeminar with USRepresentativeAllyson Y. Schwartz11/9/12 - 12:00-1:30PMColonial Penn CenterAuditorium

Contact Us

Mailing Address:University of Pennsylvania

423 Guardian DrivePhiladelphia, PA 19104-6021

Telephone:215-573-9720

E-mail:

chibe@mail.med.upenn.edu

Website: http://chibe.upenn.edu

uptake of four different cost sharing discounts for enrolling in an employer-based Weight Watchers weight loss program as well as program attendance andweight loss over 12 months among those participants who sign up for theprogram.

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