How do we get patients engaged in their care?

According to a meta-analysis published in the Annals of Internal Medicine (2012), Americans are failing to comply with medication prescriptions and it’s costing them anywhere between $100 billion to $289 billion a year. 20 to 30 percent of prescriptions are never filled and almost 50 percent of medications aren’t taken as prescribed. (Annals of Internal Medicine, 2012) Medication non-adherence causes approximately 125,000 deaths a year and up to 10 percent of all hospitalizations. (Annals of Internal Medicine, 2012) Although this non-adherence is troublesome to providers it has not affected their bottom lines thus far. However, the Patient Protection and Affordable Care Act (PPACA) is shifting focus away from the current fee for service reimbursement model to one where healthcare organizations are reimbursed on healthy outcomes for the consumers they serve. This focused attention on outcomes and consumer-based models will force healthcare organizations to look for ways to influence and impact consumer behavior to positively affect their health. Savvy providers will establish more effective, meaningful interactions with their patients and increasingly promote better health outcomes through comprehensive engagement strategies. Gamification platforms built on theories of behavioral economics holds significant potential to achieve both of the above goals.

Behavioral economics seeks to understand how people make decisions and what motives and incentives influences decision making. Conventional economics is built upon a premise that humans are rational actors who consistently choose options that advance their self-interest, however, in behavioral economics that people are predictably irrational in their decision-making. Principles such as “loss aversion” – tendency to be more sensitive to the prospect of loss than the possibility of gain and “present bias” which leads people to pay more attention to immediate costs and benefits than equally significant ones that are likely to occur in the future (Wikipedia) can cause counterproductive decision-making. Therefore, health care providers must develop individual–centered incentives or “behavioral nudges” that facilitate patient engagement, support decision-making, and enable achievement of health promoting goals. For example, the Center for Medicare and Medicaid Innovation is funding a trial to improve medication adherence and health outcomes in patients recovering from acute myocardial infarctions. In this trial, patients are provided a “smart” pill bottle that tracks and transmits data about medication use. Each day, patients who have taken their medications are eligible to win cash prizes in a daily sweepstakes system and are contacted the following the day telling them whether they won the prize – or would have won if they had taken their medication. These small but frequent sweepstakes take advantage of people’s tendency to prefer immediate rewards, and also play on the desire to avoid regret. (Volpp et al) Creating individual-centered incentives rather than one-size-fits-all approach allows individuals to “self-match to incentives and engage them in the decision making process. This could lead to better participation and more successful goal achievement.” (Robert Wood Johnson Foundation) Dimensions to be considered when designing person-centered incentives include: risk preferences, personal tastes, competitiveness, altruism, loss aversion, and timing preference. (Journal of Workplace Behavioral Health, 2014)

Gamification is the application of game elements and digital game design techniques to influence behavior in non-game settings. (Wikipedia) Tools such as points, achievement badges, or mastery levels are all dynamic methods to interact with customers through the medium of games. According to a leading information technology research and advisory company, by 2015 more than 50% of organizations will be using gamification and business will spend $2.8 billion dollars on gamification in 2016. (Gartner, Inc) Smartphones are effective conduits for gamification because they include features such as GPS services, accelerometers, and external sensors.  Consequently, health-related apps are quickly taking hold at rapid-fire speed. These apps are being designed to monitor every facet of an individual’s health profile ranging from activity and sleep to nutrition and vital signs. Key areas where apps will make an impact include nutrition, weight management, disease prevention, self-management, adherence, cognitive, and mental health. Telehealth is another burgeoning area of care that could use gaming as a channel for promoting and encouraging healthy outcomes.  Healthcare organizations have only just begun to scratch the surface to the varied applications of gamification. Additionally, technological advancements such as gesture and sensor recognition technologies will continue to drive and evolve gamification utilization in health care.

However, new technologies that track behavior and connect with patients are not in and of themselves going to change behavior in high-risk patients. In order for to achieve improvements in adherence rates, technology has to be combined with personalized incentive schemes. For example, Volpp et al describe an approach called “automated hovering.”  This is a cost effective method to monitor patients and deliver targeted feedback. Such hovering can provide clues about why patients are not adherent to medication regimens. Currently, all a provider knows is that the patient has not filled a prescription. (NEJM, 2012) Additionally, video games are designed to motivate users behaviors using techniques such as conditional rewards that risk being lost if gamers do not return frequently to play. This plays well on the well known tendencies of loss aversion and to irrationally value things they hold over things they do not have.

Evidence supporting gamification in health is starting to emerge. (Am J Prev Med, 2012) However, there are a number of issues that need to be addressed in order for gamification platforms to be successful in influencing ingrained health behaviors. Firstly, a multidisciplinary approach must be utilized with experienced game developers working in tandem with clinicians and behavioral scientists. Secondly, factors such as regulation and accreditation must be considered to provide consumers with assurance regarding quality.

In conclusion, as reimbursement schemes shift from a fee for service model to a fee for value/outcome based model, healthcare providers will be increasingly apt to engage patients in more meaningful and innovative ways. Preliminary work on behavioral economics coupled with gamification platforms has yielded positive results. Therefore, as we progress with technological advancements, look for healthcare providers to invest in these programs at significant risk with the hopes of decreasing costs while increasing quality and access of healthcare.

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