In moving from healthcare to health, consumers and patients must be enabled to make healthier, more cost-effective choices.
A large part of success may be determined by how we develop incentives to bring attention and pull to those choices. One of the leaders in this area, who’s been driving successful consumer engagement through incentives for over a decade, is Michael Dermer, Chief Innovation Officer at Welltok. I had the pleasure of sitting down with Michael a few weeks ago to talk about what we can do to help people make the right choices for health.
Here is part one of my Interview with Michael Dermer, the Chief Incentive Officer at Welltok, developer of CafeWell, a leading health optimization platform, that rewards participants for leading healthier lives.. In Part II will discuss a bit more about Apple and how to get different populations engaged.
LK: As we move from health care to health (projections are that half of payments will be value-based by 2022, according to Leavitt Partners), tell us how you got into the health incentive business, a little of the IncentOne story (Michael Dermer’s previous company that was acquired by Welltok just over a year ago), and why it’s so important to this Copernican moment, where patients move to the center of the universe of health care.
MD: If you go back 10 or 15 years ago, I was a corporate lawyer in New York and just randomly stumbled upon the incentive business and ultimately the health care business. I had seen statistics that said for women who follow their prenatal care, their costs are (generally) the costs of the tests and the delivery claims. But for those who don’t follow their prenatal care, the risk to themselves and the increased risk to infants can cost the healthcare system literally millions of dollars.
That just really struck me that the medical profession knew what behaviors they wanted consumers/patients and even providers to take, but weren’t very good at getting people to do what are often simple, proven things (to reduce health risks) even in situations where the intrinsic motivations are seemingly very high.
In every other industry other than healthcare, incentives and rewards were and are a foundational way to accomplish that. So, in the mid 2000’s with IncentOne, we said, if it all comes down to consumer and provider behavior, then incentives aren’t just a one-off, $25 reward for a health risk assessment, for example, they’re a foundational asset that should be a cornerstone to your consumer and provider engagement strategy.
Back then incentives were kind of like witchcraft and people would say we’re never going to pay people to do things they should be doing already. So it’s been a really interesting ride to see how things have evolved to where incentives have become a cornerstone tool (to health) and the success we’ve achieved with IncentOne and now with Welltok.
LK: So tell us about some of the incentives you’ve used, how things have changed in the incentive business, and what’s coming in the near future.
MD: If you go back, consumer-based incentives, delivered via self-insured employers and some health plans, were really basic: complete a health risk assessment, sign on to a portal, maybe go see your PCP, biometric screening, etc. As more and more wellness programs became prevalent in both employer and health plan communities, they started to do more around smoking cessation and online coaching. So if you look at it holistically, as the different health assets were being deployed by anyone who bore the risk, more and more of those behaviors started to be rewarded.
Fast forward today, think of telemedicine to transparency tools, to wrapping them around digital devices and apps in addition to all the traditional things around biometrics and outcomes. We have a real extension to providers with things like e-prescribing and the ACO infrastructure. What do we get from changing the behavior of providers?
So it’s been a constant evolution. Once people say “we know what the behaviors are, we know what impacts the system” then it becomes an evolution from the basic things like screenings and primary care to how to redirect people from the ER if they have the sniffles to a more appropriate care center (and much more specific decisions points). I think we now have over 6,000 behaviors we’ve rewarded over the years.
LK: So with things like telemedicine, you’re saying, “Hey, call in instead of going to the clinic and we’ll reward you for that?”
LK: What kinds of rewards do you offer for those kinds of things?
MD: Our view of the world is that different players in the healthcare continuum would want to use different dollar values and offer different types of rewards. So we always look at those two things differently.
Our first part is, how much do you actually give someone? If you give someone $50 to do a screening, you’ll get a lot more participation than if you offer $50 to run a marathon. So our first part, was what’s the dollar value? And the second part, what are all the different rewards? So from an administration perspective, that means everything from cash to HSA and HRA contributions, premium credits, gift cards, debit cards, that whole continuum of rewards that’s used in the most prevalent way. In our view of the world, the rewards that approach cash have the best results, and it’s the amount that you’re giving someone relative to the value of the behavior that is the true art and science behind all of this.
LK: Do we always get those lines to cross, between the behavior and the reward? Does it always make sense?
MD: That’s really the rub at the end of the day. So if you take things, a simple example, like you sprain your ankle and you need an MRI, and you need to decide where to have it done. At one place it’s $600 and one is $1,800, that’s simple and it’s easy to create appropriate incentives to steer people to a different service center in that instance. When you get a little deeper into long-term behavior change, that’s more complicated.
You know stopping smoking and managing nutrition and weight have longer-term benefits, but are harder [to change]. So it’s a matter of managing the benefit and the value of the behavior. It’s hard to get someone in Medicaid to stop smoking, but it’s not so hard to get them to go to a primary care doc for $50.
So, one part is how much you give them and the second part is how much it’s worth. There are lots of behaviors that have near-term benefit, the hope is that then leads to some intrinsic motivations and longer-term behavior change, but it ultimately comes down to how much you’re saving.
LK: Is the goal that these extrinsic rewards eventually become intrinsic rewards?
MD: They work hand in hand, neither will get the job done by themselves. I don’t think we’ll ever see a day where we don’t need extrinsic rewards. With all the changes in health care, you see them everywhere. If you work for a large, self-insured employer, they’re becoming commonplace. But extrinsic rewards don’t work on their own either, so what you want to do is use extrinsic for one-and-done kinds of activities, like choosing a place to have an MRI done, and then unlock more intrinsic motivations.
You’ll hear lot of stories like someone says, “Yeah, I never really exercised and never really thought about it, but I did a 10,000 step program, in response to an incentive, and something clicked.” Or a family member got them to join a competition and something clicked because they were part of a competition together. All of these things become arrows in your incentive quiver.
I’ll also say, when you look at the numbers, there’s no starker example than prenatal care. The idea of not following prenatal care may seem pretty foreign, but it’s commonplace even with so much intrinsic motivation, so we need to deploy extrinsic with intrinsic to optimize where you end up.
LK: So, let’s look at how much it takes to drive these incentives. You’ve collected a lot of data for more than a decade. Do have a good idea where to start? If you look at, say, airline miles, they’re worth maybe somewhere between a penny or a nickel. How do you know what it will take to drive a specific behavior?
MD: The reason I mentioned before that things need to be closer to cash is that you don’t want people to have to do those kinds of conversions. It’s just dollars. You’re getting real dollars. What we can do now that we have been doing this for over a decade, is we know what dollar value it takes to motivate around a certain behavior.
Our methodology is, we look at behavior in five different categories from simple things, like doing a health risk assessment, all the way up to changing lifestyle on the other end of the spectrum. And with all our data, we know how much reward will get you how much behavior change.
LK: How do you get people started on these programs? How do you get them in front of those that need to hear about them?
MD: If you think about the major sponsors, health plans, employers, now even more government agencies, reward and incentive messages are integrated into those offerings. So, if an employer is going to spend $1,000 on rewards, it becomes part of their health and wellness brand and communications, and the same goes for health plans. While health plans have been a little more tactical up until now, we’re not too far away from every health plan having a reward program just like credit cards, airlines and hotels. In the near future, we’ll see reward programs become a pretty core part of why consumers engage (with health plans), and it’s already becoming a core part of the communications strategy.
LK: In this new model that we’re heading toward, moving from healthcare to health, it seems like the core pieces are in three buckets: 1) there’s big data and analytics; 2) there’s measurement, health, sensors and home monitoring; and 3) then there’s incentives. It really seems like what Welltok and you are doing is really pulling all these components together on a common technology platform. How do all these pieces fit together, are we headed toward a behavioral health currency of some sort?
MD: It’s really interesting the way you describe it, because people used to say it’s preventative, or now it’s transparency, but we look at as all of the above. We say it’s a universe of behaviors, and they each might have immediate, intermediate, or long-term incentive applications.
One of the analogies from outside health care is Citibank. Citibank for years, like many large financial institutions, used to have these disjointed incentive programs. You’d get, say, a $200 television for opening an account, $50 for sitting down with a small business manager, and 1% back for using your credit card. Now that’s all rolled into a program called Citi ThankYou Rewards where everything you do with Citibank is rolled into one rewards program.
Another example is children with asthma. Parents might take their kids to the ER four times a year, but if they just had a fast-acting inhaler prescribed, they’d be safer and better off and it would save the system thousands and thousands of dollars.
So, with the list of different examples and risk factors, different associated behaviors, and all the assets that the health plan and employers are delivering is endless. So, I think we’ll soon see a continuum where it all comes together and starts to look a lot like ThankYou rewards, but for healthcare.
Thanks to Michael Dermer! Stay tuned for Part II on how to approach different patient populations and what the Apple Watch may mean for health care incentives and payments.
During this tech boom, is it a coincidence that the tech savvy San Francisco Giants are in the World Series for the third time since 2010? In this post, we take a look at the relationship of technology, leadership, big data analytics, and baseball. In particular, we explore how Major League Baseball manages its player/patient population, and the trends they are following since converting players from paper medical records to EHR.
Baseball teams are very secretive about how they use their data. Teams, like the San Francisco Giants, employ a slew of data analysts and data tools, but every team is reluctant to share how data is used, and where they derive insights. According to the 2014 SABR Analytics Conference, the new frontier of baseball data is not just about scouting players, but keeping players healthy and injury-free. The new area of research, just in in its infancy, is marrying baseball statistics with medical injury research.
Medical analysts are the new data darlings of baseball operations.
Chris Marinak, Sr. Vice President of Major League Baseball, implemented MLB’s switch to electronic medical records, and believes medical injury research will provide new insights over the next five or ten years,
I actually joined MLB in 2008, and I was shocked to see that we didn’t have a system for tracking injuries or medical information at a de-identified level. We were literally keeping a lot of paper documents and putting them into a filing cabinet. It was time for us to get into the 21st century.
So starting in the 2010 season, we rolled out an electronic medical records system working with the players’ association that allows our medical staff to enter in medical information on every single player injury and the treatments that those players get. And then that information is all stored in one place, so that when you go from one team to the next, it flows along with you.
Marinak says the ancillary benefit is that MLB now has an injury tracking system where they can track trends in the industry.
This data is analyzed at a de-identified level to find the drivers of lost time, and the injuries keeping players off the field. “So we can hopefully keep them healthier,” according to Marinak.
Baseball is a sport that has always been hungry for statistics. Sabermetrics, the study of baseball’s in-game play, has been around since the middle of the 20th century. But in 2002 and 2003, Sabermetrics became “Moneyball” as the Oakland As advanced to the playoffs with their analytic approach to assembling a competitive team, despite a lack of competitive dollars.
With the advent of new technologies, PITCHf/x data and Sportsvision video in 2006, the world of baseball was set to explode with big data and predictive analytics. Detailed data became accessible for every hit and pitch in a game.
Batting and pitching biomechanics also started to be video analyzed at the high school level. In 2009, my son clocked an official bat speed of 101 miles per hour, one of the fastest recorded bat speeds in the country for any amateur or professional player.
Bat speed is recorded via a static ball test, hitting off of a tee; exit speed is recorded hitting a pitched ball.
An injury sidelined his play, so he started experimenting with this new PITCHf/x data. His early web-based program would let you compare MLB pitchers and batters, and team matchups. Having baseball experience would help him provide insights for an individual player’s performance enhanced by data visualizations like heat maps.
Although PITCHf/x stated its data could not be used for commercial purposes, it didn’t take long for the financial world to play ball – Bloomburg Sports was born in 2011. The company’s latest technology (recently sold) has the capability to create every imaginable data point from video captured from play performance, whether that video is captured live or from a stream.
Do you want to know how many times a player licks his lips before fielding a ball? – Dan Cohen, Bloomberg Sports
Dr. Glenn Fleisig of the American Sports Medicine Institute says they look at what a person’s body is doing and that’s what biomechanics is, “Tracking where the ball went is all good, but we look at how did their body get there. The new thing teams are embracing is biomechanics.” More information will come from wearable tech and self-tracking technologies.
MLB is doing a lot more tracking of player movements utilizing Trackman and through studies at MIT. Marinak says having more of that information publicly available will be important to innovation, but right now it’s just too big, “A game’s worth of data in Trackman is 7 terabytes. So we’re talking about big data at a massive scale.” He cautions that how this data is treated will be different because it is medical information, and keeping a player’s medical information needs to be private.
Dr. Stan Conte (formerly with the SF Giants and now with the Los Angeles Dodgers) is a leading expert in medical injury research in baseball. He says they focus on “changes” in the data. He explains medical data is dirty data, so it is very difficult to analyze.
The data is getting better, and with more data, we’ll be able to go into areas that we hadn’t thought about before. – Dr. Stan Conte
But now that PITCHf/x also tracks every defensive play, it has been reported that the San Francisco Giants do defensive shifts better than all MLB teams. Is the team’s proximity to Silicon Valley, and its innovative CIO Bill Schlough, its World Series advantage? Or is it their overall focus on innovation?
The San Francisco Giants are dedicated to enriching our community through innovation and excellence on and off the field.
In 2004, the SF Giants were the first to offer Wi-Fi throughout their stadium. Today, approximately 35% of fans are online at games. The stadium’s “fat pipe” allows fans to easily upload content via the Giants app or social channels like Faceboook, Twitter, and Instagram.
In 2009, SF Giants CIO Bill Schlough introduced dynamic ticket pricing (DTP), allowing the price of game tickets to go up or down depending on popularity and availability. Other teams now use DTP, and the idea has spread to restaurants, movie theaters, and the performing arts.
— #OctoberTogether (@SFGiants) June 24, 2014
This year, the SF Giants opened a 4,320 sq. ft. edible garden and restaurant, affectionately called the “kale garden”, that sits overlooking center field. In addition to providing healthy fare for fans and players, the innovative garden will be used as an open-air classroom for students during the Giants’ off-season, where Bay Area youth will go to learn about sustainability, urban farming and healthy eating.
Gaining respect early as a technology leader was key for Schlough’s career, as the Giants let him run his own department with the ease and precision he wanted to do it in. It’s tremendous the impact Schlough has had on the Giants, but eventually that impact will affect the MLB as a whole. – Justin Kasser
Now, let’s play ball!
First, do no harm.
Four simple words that are synonymous with healthcare. It’s a principle that everyone in the industry – not just physicians – should adhere to.
So shame on us all for our part in allowing an EHR vendor to shut off a practice’s access to their patients’ medical records and for recklessly putting patients at risk.
Background: Full Circle Health Care in Maine purchased an EHR from HealthPort in 2010. Originally the maintenance fees were $300 a month. A few months later CompuGroup Medical purchased HealthPort and increased the maintenance fees to $2,000 a month. The practice protested the price increase and claimed CompuGroup failed to deliver hardware upgrades that had been paid for. The parties spent several months arguing and for 10 months the practice did not pay its maintenance bills. Finally in July, CompuGroup shut off the practice’s access to its medical records.
The details as to why the fees jumped so much and whether CompuGroup had the legal right to do so are a little unclear. What is clear is that multiple parties are at fault for allowing such a mess to occur.
Let’s start with the government, which created the HITECH program and promised thousands of dollars for providers willing to adopt and meaningfully use EHRs. Though the objectives were admirable, CMS failed to adequately address all the “what if” scenarios in its rush to move the program forward. The legislation and final rule provide no guidelines for protecting patient records in the event of a vendor/provider disagreement, financial hardship, or business discontinuance. Undoubtedly we’ll see plenty more disputes like this one in the coming years.
The practice also gets a share of the blame. The owner should have invested in legal advice before signing a $72,000 contract for something as critical as an EHR system. Did she skip this step in her haste to achieve Meaningful Use and earn incentive payments? Furthermore, even if she disputed the increase in maintenance pricing, shouldn’t she, at a minimum, have continued paying the $400 a month fee she believed was the correct amount? Perhaps the vendor would have been more willing to come to an acceptable agreement if she hadn’t stopped paying altogether.
CompuGroup, of course, looks like the really bad guy here. The multi-national company has annual revenues of about $600 million. Did they really need to pull the plug on this practice over a piddling $40,000? The company’s general counsel says the situation is similar to an electric company shutting off power when a customer fails to pay. Perhaps, but many municipalities and some states have laws that prohibit the discontinuance of services under certain conditions, such as in extreme cold weather or when a child or sick person is in residence. In other words, there are laws to protect consumers against potentially harmful actions. (See: EHRs And The Law: When Interoperability Isn’t a Choice)
Which brings us to the seemingly forgotten patient, who arguably is – or should be – the owner of his or her own record. We do have federal and state laws that give patients the right to access and inspect their medical records. Perhaps the practice’s 4,000 patients should all send CompuGroup a written request for a copy of their records. Maybe an attorney who is smarter than me should look into that.
Until the mess is settled, we have a practice seeing patients without the benefit of medication and allergy lists, details on previous treatments, or lab and test results. And everyone involved is hoping that no patients are harmed.
Whether our role in healthcare is policy maker, technology developer, provider, or HIT geek, we really need to do better.
Industrial designer Marc Harrison suffered a brain injury while sledding when he was 11-years old. The injury and years of rehabilitation would provide Harrison with insight and inspiration for his future work in industrial design.
Harrison would go on to develop the philosophy of Universal Design – the idea that products should be developed for people of all abilities, not just for people of average size, shape, and ability.
Harrison’s study of people with disabilities led to the iconic design of the Cuisinart food processor, a design still relevant today after more than 40 years. The simple, clean design would also come to be a major influence for Steve Jobs in the development of the Macintosh computer.
If you put the original Mac in 1984 side-by-side with an early ’80s Cuisinart, the influence on the physical design of the Mac is immediately obvious. Not only is the Mac designed with software for accessibility and more universal design, but its physical design had this perhaps unknown influence as well. – Dean Karavite
I learned about Harrison from an exceptional interview with Dean Karavite, a Human Interaction Specialist in Clinical Informatics at Children’s Hospital of Philadelphia. Dean was interviewed by Whitney Quesenbery, co-author of the book, “A Web for Everyone”.
It is important to point out that people with disabilities are not all people in poor health.
People with disabilities use the health care system a lot and in many different ways. –Whitney Quesenbery
Among study participants with various levels of disability, Dean found that people with the highest level of needs – those also with many chronic conditions – were the source of “the most detailed, sophisticated, and innovative ideas on what an accessible PHR should do.”
Understanding what users want and the problem the application will solve should be the first step in any development process. How does user-centered design firm IDEO find people to interview for needfinding? While it is great to speak with average users, the most interesting interviews come from “extreme users.” This idea of extreme users is also explored in “Just Ask: Integrating Accessibility throughout Design” by Shawn Henry.
As part of our project exploring accessible Personal Health Records, one of the methods we have applied was performing a survey with 150 people with different disabilities. In that survey, we had our participants rate over 20 health topics in two ways.
First, in terms of how important the particular topic was to their health and healthcare, and second, their current level of satisfaction with a particular issue or topic.
The number one, most highly rated issue in terms of importance was the ability to share medical information between different providers’ offices, and hospitals.
The real underlying issue here isn’t just the transfer of data, but care coordination, which is the collaboration, not just communication, but collaboration between multiple healthcare providers. – Dean Karavite interview with Whitney Quesenbery
Another part of the “Accessibility Designs” project looked to assess the current state of PHR systems for accessibility, functionality and usability.
Unfortunately, vendors were reluctant to participate.
These results came from systems project team members used to manage their own health including a hospital PHR, an ambulatory PHR, and a consumer PHR.
According to the project, “The hospital PHR was the least functional and least usable, yet was the most accessible. Meanwhile the ambulatory PHR was the most functional and most usable, yet failed to meet basic accessibility standards. The consumer PHR was quite usable despite failing to meet accessibility criteria, and failed one crucial accessibility requirement: the entry of dates by people with visual and/or physical disabilities, a critical action required by almost every task managed by the system.”
Many of the technologies used today are the result of work used to meet the needs of people with disabilities:
“For example, touch screens, on-screen keyboards with word prediction, zoomable displays, speech recognition, text-to-speech. Think about it. It took about 10 to 15 years, and now we all have it on our computers, our phones and other devices, and we absolutely love it.” – Dean Karavite
Get out of your little box and look for inspiration all over the place.
Good ideas can come from anywhere!
I’ve been writing a lot about the benefits of patient-centered-care and patient engagement.One study published in Health Affairs examined the relationship between “patient activation levels” (which could also be called patient engagement) and care costs. In a companion piece to the study, the authors wrote that “patients who were more knowledgeable, skilled and confident about managing their day-to-day health have lower health care costs than those patients who lacked this type of confidence and skill.”
One great example of patient education not exactly hitting the mark and leaving the patient not fully engaged was told to me by a diabetic educator. I had gone for a consultation and education on how to manage a gestational diabetes diagnosis. After going over all the blood glucose values, when and how to test, when to be alarmed, etc., she asked me what I would do if I had three readings with numbers above my blood glucose level goal.
“Call my doctor,” I said. Her reply, “Excellent. You’d be surprised how many people keep great logs of their glucose readings but don’t call anyone when their levels are too high.” They understood that they were to track their glucose levels but didn’t realize they needed to report abnormal results to someone.
How can clinicians get patients to understand the nuances of their care so they will make those necessary phone calls? How can we educate patients so they understand the “whys” of the interventions and the steps they need to take to achieve their goals? To me, explaining they need to do a certain task or get a certain reading isn’t enough. They need to have some rational behind why it is important and what will be done with the information they gather.
Here are four interesting ways I found to help patients better understand care, interventions and concepts. I hope clinicians find these useful in educating and engaging their patients.
I hope you find these tools useful in engaging and education your patients. And please share your favorite tools for increasing patient engagement in the comments section.