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In This Issue
Way to Health: The Next Step in Automated Hovering Enabling Innovation: New Center is Created Research Spotlight: Kathryn Saulsgiver Translating Research Into Practice: Benefits of Working with Corporate Partners Musings of a Behavioral Economist New Initiatives

October 2012

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 October newsletter, such as our ongoing work with corporate partners and a Center for Medicare and Medicaid Innovation sponsored project to partner with the University of Pennsylvania Health System, Independence Blue Cross, Horizon Blue Cross Blue Shield, Keystone Mercy, Health First, and CVS Caremark to improve medication adherence rates. The strategy of "automated hovering" to help patients improve their health behaviors guides this project, and this newsletter presents several perspectives from those who are designing and operationalizing this strategy in the once disparate contexts of health care provision and academic research. This issue turns the spotlight on the research of Kathryn Saulsgiver, a CHIBE investigator who has been busy testing ways to help people improve their diets at a local supermarket in West Philadelphia. David Huffman, a visiting professor at Penn, is the contributor in this issue to our regular column "Musings of a Behavioral Economist" and calls for a systematic approach to research on defaults. We hope you enjoy reading this issue. Best wishes for an enjoyable fall season! Sincerely,

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CHIBE in the News

Remote Monitoring Study Offers Financial Incentives for Medication Adherence MedCity News 9/27/12 Penn-CMU Roybal

Kevin Volpp, Director Scott Halpern, Deputy Director

Way to Health: The Next Step in Automated Hovering

Automated hovering, the concept of encouraging people to change unhealthy

Center Convenes in Cape May for Annual Retreat LDI Health Economist 9/24/12 VALUE Framework to Teach Future Physicians Valuebased Care American Medical News 9/19/12 LDI Health Insurance Exchange Group Convenes LDI Health Economist 9/14/12 Lessons for the Health Care Profession Harvard Business Review 9/13/12 Will the Soda Tax Make Us Healthier? Knowledge at Wharton, 9/12/12 Soda Bans: Nanny State or Nudge? Marketplace Money 8/31/12 Way to Health Featured in "Healthcare Strategy Alert!" Healthcare Strategy Institute 8/30/ 2012 The Risks of Intentionally Unvaccinated Students Penn RN Research News 8/28/12 LDI Sponsors Summer Undergraduate Minority Research Programme The Times of India 8/27/12 Warfarin Adherence Study Cited as Crucial Health Research Wall Street Journal 8/10/12

behaviors through social media, wireless devices and other technologies, has moved to the next tier. In a recent New England Journal of Medicine article entitled "Automated Hovering in Health Care-Watching Over the 5000 Hours," authors David Asch, MD, MBA, CHIBE member and Executive Director of the Penn Medicine Center for Innovation, Ralph Muller, MA, Chief Executive Officer, University of Pennsylvania Health System, and Kevin Volpp, MD, PhD, Director of CHIBE and 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 often involves some home visits or telemedicine services, which can also include a clinician. "One problem is that using personnel in hovering is expensive and therefore 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 of Health/National Institute on Aging, it is an online tool kit to support a more efficient way of conducting behavioral economics studies. "We are very excited about carrying out this demonstration," Muller says. "This is a very intriguing hypothesis." "It is incredibly cool!" says Asch. "It provides an organized way to connect to people with the technology in their pockets. It can also help us to better understand how to engage with people in their everyday lives as well as to let us reach out to people from all over the country." When people agree to participate in a study that is part of the Way to Health Ralph Muller platform, they receive a welcome email with information about what is expected and instructions on how to participate. They also select how they would like to receive messages--text, e-mail, or telephone--and provide their payment preference for receiving incentives. Then they can log onto their personal dashboard to participate in their particular study. They can also view their notifications and upcoming study-related events. The system is interactive. In a study to measure medication adherence, for example, the enrollees are sent an electronic pill bottle. Each day the participant takes a pill, the 'cap' transmits a signal to the Way to Health portal and to the study coordinator; this creates an objective assessment of medication compliance. For another study, designed to measure the success of participants trying to lose weight, participants are asked to step on an electronic scale. Upon stepping on the scale, the participant enters a personal code and an embedded camera takes a picture. Both the photo and the participant's weight are automatically transmitted to the Way to Health portal by this specially equipped scale.

Drought May Lead to Increased Prices of Nutritious Foods Toledo Blade 7/26/12 Novel Approaches to Improve Health Behaviors The Incidental Economist 7/7/12 Value In Health Care Institute of Medicine 7/1/12

Recent Publications
Bending the cost curve through market-based incentives. Antos JR, Pauly MV, Wilensky GR. N Engl J Med. 2012; 367(10):954-958. On the Way to Health Asch DA, Volpp KG. LDI Issue Brief. 2012; 17(9). What business are we in? The emergence of health as the business of health care. Asch DA, Volpp KG. NEJM. 2012. Epub ahead of print. Self-interest without selfishness: The hedonic benefit of imposed self-interest. Berman JZ, Small DA. Psychol Sci. 2012. Epub ahead of print. Using mHealth technology to enhance self-monitoring for weight loss: A randomized 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, Kathryn Saulsgiver, 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-scale randomized clinical trials running on the platform," says Beth Stearman, Research Project Director at CHIBE. "All use the same core Way to Health functionality with customization based on study design. At full capacity, we will be able to run a really high volume of studies at the same time." Although the final reports aren't in yet, expectations remain positive. "If successful, 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 and efficiency 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 nurses do." -Nan Myers

Enabling Innovation: New Center is Created

Recognizing that changes are needed to the healthcare landscape, and looking for ways to ensure that the right steps will be taken to implement them, in late 2011 the University joined with the Health System to create the Penn Medicine Center for Innovation (PMCI). Led by Executive Director David Asch, MD, MBA, along with Co-Directors Kevin Volpp, MD, PhD, who is also Director of CHIBE, and Kevin Mahoney, Senior Vice President and Chief Administrative Officer of the Health System and Vice Dean of Integrative Services at the Perelman School of Medicine, it is also a partnership between the School of Medicine and the Leonard Davis Institute. PMCI was developed specifically to facilitate and implement innovation within

Increasing supplemental nutrition assistance program/electronic benefits transfer sales at farmers' markets with vendor-operated wireless point-of-sale terminals. Buttenheim AM, Havassy J, Fang M, Glyn J, Karpyn AE. J Acad Nutr Diet. 2012; 112(5):636-641. Health service use among the previously uninsured: Is subsidized health insurance enough? Decker SL, Doshi JA, Knaup AE, Polsky D. Health Econ. 2012; 21(10):1155-1168. Impact of cost-sharing on treatment augmentation in patients with depression. 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 store marketing strategies and obesity: An integrative review. Glanz K, Bader MD, Iyer S. Am J Prev Med. 2012; 42(5):503-512. Beneficiary or benefactor: Are people more prosocial when they reflect on receiving or giving? Grant A, Dutton J. Psychol Sci. 2012;23(9): 1033-1039. Shaping end-of-life care: Behavioral economics and advance directives. Halpern SD.

the Health System and the School of Medicine. Its mandate is to focus on improving the patient experience, anticipating and responding to changes in healthcare financing and identifying ways to achieve positive health outcomes for employees, patients and the community. By combining the expertise of faculty members of the School of Medicine and David Asch the Wharton School, "it is helping us to bring some of the best practices to the Health System," explains Roy Rosin, MBA, Chief Innovation Officer for PMCI. "We know that the future of healthcare will be outcome- and value-based and that we need to engage a broad, interdisciplinary team to chart a path to a different way of conducting business."

Roy Rosin

"Given that we know what is coming, we have to learn how to get there," Rosin adds. To support this mission, the PMCI invited input and representatives (including students) from throughout the University and Health System to participate in the Innovation Center. "We found that with the more different perspectives 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 was noted that members would test how insights from behavioral economics can improve patient health and reduce the rate of healthcare costs. One of the first projects undertaken by the Innovation Center was to look at the culture of innovation across the Health System, explains Shivan Mehta, MD, Director of Operations for PMCI. "We coordinated a 'Big Ideas' campaign which asked for ideas to improve the patient experience, and opened it up to the entire Penn Medicine staff. Our goal was 500 responses; we received 1,739. We winnowed down the responses to the most promising ideas, which were then escalated to facilitator-led workshops Shivan Mehta and translated into draft business plans. The final stage involved 10 teams of finalists. We are currently working with the winning teams to advance their ideas to implementation within the Health System." (Follow this initiative's progress here.) Mehta says one of the tenets of PMCI is that "we are working with teams to evaluate ideas and research solutions. We must actually be sure that they are solving the right problem. Throughout the process we continually measure, test and, 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 a problem." -Nan Myers

Semin Respir Crit Care Med. 2012;33(4): 393-400. Perceptions of organ donation after circulatory determination of death among critical care physicians and nurses: A national survey. Hart JL, Kohn R, Halpern SD. Crit Care Med. 2012; 40(9): 2595-2600. Measuring the prevalence of questionable research practices with incentives for truth telling. John LK, Loewenstein G, Prelec D. Psychol Sci. 2012; 23(5): 524-532. Organ allocation policy and the decision to donate. Kessler JB, Roth AE. American Economic Review. 2012;102(5): 2018-2047. Randomized trial of lottery-based incentives to improve warfarin adherence Kimmel 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-based approaches to adherence. Kimmel SE, Troxel AB. Clin Trials. 2012. Epub ahead of print. Effect of the Medicare Part D coverage gap on medication use among patients with hypertension and hyperlipidemia.

Research Spotlight: Kathryn Saulsgiver

While psychologist and behavioral pharmacologist Kathryn Saulsgiver was at the University of Vermont completing her postdoctoral behavioral pharmacology research among substance abusers, she heard a visiting Kevin Volpp describe his GE smoking cessation study and decided to seek a position at CHIBE. Saulsgiver is now a Research Associate at the Center and leads Scott Halpern's Way to Quit R01 investigation that uses the Way to Health research platform to evaluate incentive-based behavioral economic interventions to help people quit Kathryn Saulsgiver smoking. Inspired by her mentors Volpp and Halpern, Kathryn proposed and received funding for her own pilot research project, Way to Healthy Eating, a behavioral economic intervention to increase fruit and vegetable purchasing among low-income West Philadelphia grocery shoppers. What drew you to this project? I saw parallels between substance abuse and unhealthy eating. Both maladaptive behaviors emerge from independent choices which, in some cases, can become self-destructive habits. Unfortunately, these types of hard-to-break habits are easy to establish, and the world views these habits as a choice that the individual could easily change. For both behaviors, however, environmental circumstances such as price differentials and social interactions are nudging individuals towards these unhealthy choices. I thought that these similarities might make poor eating habits amenable to behavioral economic interventions. What were you trying to achieve? Currently, grocery shoppers in a low-income West Philadelphia neighborhood near Penn spend less than six percent of their grocery budget on fruits and vegetables. I tried to raise that to at least fifteen percent with the Way to Healthy Eating study, which was a four-arm trial that compared information provision and flat and tiered incentives with no intervention. All participants, except those in the control arm, received feedback on their grocery shopping habits. Participants in the flat incentive arm were also reimbursed fifteen percent of their total grocery bill if they hit the fifteen percent fruit and vegetable purchasing goal. People in the tiered incentive arm could be reimbursed fifteen, twenty or twenty-five percent of their total grocery bill depending 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's Superstores, the company that owns the ShopRite not far from Penn, where we based our research. Mr. Brown has established Uplift Solutions, a non-profit organization dedicated to addressing limited food access, substandard education, inadequate safety, and unequal opportunities faced by residents of 'at risk' neighborhoods. Mr. Brown allowed my research team to set up a recruiting table in his West Philadelphia ShopRite store and provided access to our participants' shopping data via the "Price Plus" shopping card program. We

Li P, McElligott S, Bergquist H, Schwartz JS, Doshi JA. Ann Intern Med. 2012; 56(11):776-784. Can behavioural economics make us healthier? Loewenstein G, Asch DA, Friedman JY, Melichar LA, Volpp KG. BMJ. 2012;344:e3482. Concepts of healthy diet among urban, low-income African Americans. Lucan SC, Barg FK, Karasz A, Palmer CS, Long JA. J Community Health. 2012; 37(4):754-762. Parental decisionmaking preferences in the pediatric intensive care unit. Madrigal VN, Carroll KW, Hexem KR et al. Crit Care Med. 2012; 40(10):2877-2882. Public opinion about financial incentives for smoking cessation. Park JD, Mitra N, Asch DA. Prev Med. 2012. Epub ahead of print. The New York Times readers' opinions about paying people to take their medicine. Park JD, Metlay J, Asch JM, Asch DA. Health Educ Behav. 2012. Epub ahead of print. Leveraging insights from behavioral economics to increase the value of healthcare service provision. Patel MS, Volpp KG. J Gen Intern Med. 2012. Epub ahead of print. Effectiveness of interventions to

used the data to determine eligibility for incentives and as the basis for feedback and 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 same store twice in a month. They follow coupons and circular deals for the best bargains. These completely rational behaviors made it difficult for my research team 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 grocery store to effectively evaluate this intervention in low-income communities. So, in partnership with Uplift Solutions and ShopRite, I hope to widen the scope of the project to include multiple stores. In the meantime, I will continue working with Dr. Halpern on Way to Quit and with Dr. Volpp on a demonstration project testing a variety of incentives for the prevention of chronic disease among people receiving Medicaid in New York. -Christine Weeks

Translating Research Into Practice: Benefits of Working with Corporate Partners

Part of the CHIBE's mission is to engage private and public sector partners to develop and test scalable and cost-effective applications. This objective is part of our mission due to the importance of translating research into practice and thereby making a difference in how effective programs are in improving health. In pursuit of achieving this objective, we have established several partnerships with a number of different corporations. The types of partners that we have engaged range from large health insurance companies to employers and Joelle Friedman pharmaceutical benefit management companies. Typically we are approached by an outside organization that has identified one or more pressing challenges that they are facing. Collaboratively, we then develop and propose research projects which test different ways of addressing those challenges. Once an approach is agreed upon, we then embark on planning and implementation of the project, with a focus on ongoing evaluation and refinement of the programs that we develop. As researchers, it is always exciting to see applications of our research in the field. Recently, we worked with a large health insurance company to develop a new insurance product. The development process included behavioral economic thought leadership around the new benefit design coupled with in-depth market research. We introduced a rigorous research component into the product development cycle which was unique for this organization. As with most large organizations, this particular research partner rarely has the time to vet their benefit design assumptions with various stakeholders as they are usually so focused on completing milestones. As a result of our expertise, the new benefit design is grounded in evidence-based research. In addition, the research that

increase screening for breast, cervical, and colorectal cancers: Nine updated systematic reviews for the guide to community preventive services. Sabatino SA, Lawrence B, Elder R, Mercer SL, Wilson KM, DeVinney B, Melillo S, Carvalho M, Taplin S, Bastani R, Rimer BK, Vernon SW, Melvin CL, Taylor V, Fernandez M, Glanz K. Am J Prev Med. 2012; 43(1):97-118. Incentivising personal responsibility: Conceptual clarification and evidence. Schmidt H. Z Evid Fortbild Qual Gesundhwes. 2012;106(3):185-194. Cost-effectiveness of long-term outpatient buprenorphinenaloxone treatment for opioid dependence in 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 choices suck us in. Sela A, Berger J. J Consumer Research. 2012; 39(2):360-370. A transition model for quality-of-life data with non-ignorable non-monotone missing data. Liao K, Freres DR, Troxel AB. Stat Med. 2012. Epub ahead of print. Medicare's new hospital value-based purchasing program is

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

Musings of a Behavioral Economist

Defaults are in many ways the poster child for the behavioral economics movement in health. They offer the promise of a low-cost way to "nudge" people towards better health, without being overly restrictive of choice since people can always opt out. Defaults have been shown to have substantial effects on outcomes in nonhealth and health domains, including (but not limited to) retirement contribution rates, organ donation rates, flu vaccination rates, advanced directive decisions, and rates of consuming fruits and vegetables during school lunch.

David Huffman

At this point, however, there is still limited knowledge about why defaults work. A variety of different mechanisms have been proposed - implicit recommendation, procrastination in opting-out, inattention, desire to minimize regret - but the relative importance of these different channels has not been established. Defaults in different settings may necessarily vary in the strength of these various features, and it is not known how this will impact the effectiveness of the default. For example, whether an employer or a doctor sets a default might affect the perceived value of the implicit recommendation. As another example, in some policy-relevant settings it may not be possible to offer a delayed opportunity to opt out, removing the procrastination "lock-in" effect; it is not clear whether defaults will be strong when lacking this feature or not. There is also growing number of published examples where defaults did not affect behavior, or at least not in a cost-effective way. For example, when the default contribution for 401(k)s was increased to the relatively high level of 12%, most people opted out. In another case, a default to encourage low-income tax filers to save part of their tax refund had little impact, as people almost universally opted out. Making a portion of fruits and vegetables the default for school lunches increased consumption of fruit and vegetables, but also lead to a massive increase in the amount of wasted fruit and vegetables. Defaults remain a very promising lever for improving health outcomes, but the time seems ripe for more systematic research on the mechanisms underlying defaults, in order to understand when defaults will be powerful and when they will be less effective. -David Huffman

New Initiatives
Testing Behavioral Economic Interventions to Improve Statin Use

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

and Reduce CVD Risk Funded by: NIH/National Institute on Aging The application of conceptual approaches from behavioral economics offers considerable promise in advancing health and health care. In patients with suboptimal cholesterol control who are at high risk for CVD, this study will test the effectiveness and cost-effectiveness of different behavioral economic techniques to improve statin adherence following discontinuation of the intervention. Investigative team leaders Iwan Barankay, Kevin Volpp and Peter Reese will use a 4-arm randomized controlled trial to compare the effectiveness and cost effectiveness of alternative approaches to inducing habit formation among CVD patients with poorly controlled cholesterol who have been prescribed statins. Social Goals and Individual Incentives to Promote Walking in Older Adults Funded by: The Robert Wood Johnson Foundation and the Donaghue Foundation Evidence from behavioral economics suggests that people have short time horizons and difficulty trading off immediate for delayed health benefits. Little is known, however, about whether financial incentives can be effective in encouraging higher levels of physical activity among older adults, particularly when they are in the form of social goals. The goal of this pilot randomized controlled trial is to test whether a financial incentive of a donation to achieve a social goal is more effective to motivate and sustain a daily walking habit than the same dollar value given to an older adult. This study, led by Karen Glanz and Jason Karlawish, will recruit adults 65 and older to use Way to Health with a digital pedometer-internet interface. Using Behavioral Economics to Promote Medication Adherence and Habit Formation Funded by: The Robert Wood Johnson Foundation and the Donaghue Foundation Poor adherence to medication regimens is a significant problem in healthcare. This study, led by Judd Kessler, will investigate simple behavioral economics interventions to overcome cognitive and motivational barriers to medication adherence. The goals of this study are to analyze which interventions are most effective in promoting medication adherence; to analyze which interventions are most effective in promoting long-term habits that persist even when the interventions are removed; and to understand how various patient characteristics predict adherence or treatment receptivity. Cost Sharing Impact on Uptake and Attendance Among People in a Workplace Weight Watchers Program Funded by: Weight Watchers, Inc An important unresolved question in the incentive literature is how to optimally set patient cost-sharing for services that require ongoing patient engagement. Standard economic theory would suggest that lowering prices to zero (or even below zero) would maximize program attendance; however, the goal of the Weight Watchers program is not attendance per se but weight loss and it is possible that people who come to the program because it is lower cost or free will value it less and thereby exert themselves less and be less successful in losing weight. It is also unclear how much attendance would change with changes in price and whether the increased attendance would be worth the cost of the subsidies. This study, led by Kevin Volpp and Leslie John, will test the

Awards
Peter Reese Presidential Early Career Award for Scientists and Engineers Scott Halpern Department of Medicine Austrian Award

Upcoming Events
Wharton Decision Processes Colloquia: Fall Series 2012 12:00-1:30pm Huntsman Hall Room 340 10/15- Michael Tuan Pham 10/29- Thomas Gilovich 11/5- Nicholas Epley 11/12- Clayton Critcher 11/26- Phil Fernbach 12/3- Anuj Shah LDI Post-Doc Recruiting Seminar with Michael Richards, MD, MPH 10/12/12- 12:00-1:30PM Colonial Penn Center Auditorium LDI/Wharton Penn Risk Insurance Program Research Seminar with Amy Finkelstein, PhD 10/19/12 - 12:00-1:30PM Colonial Penn Center Auditorium LDI Research Seminar

with Nicole Maestas, PhD 10/26/12 - 12:00-1:30PM Colonial Penn Center Auditorium LDI Health Policy Seminar with US Representative Allyson Y. Schwartz 11/9/12 - 12:00-1:30PM Colonial Penn Center Auditorium

uptake of four different cost sharing discounts for enrolling in an employerbased Weight Watchers weight loss program as well as program attendance and weight loss over 12 months among those participants who sign up for the program.

Contact Us
Mailing Address: University of Pennsylvania 423 Guardian Drive Philadelphia, PA 19104-6021 Telephone: 215-573-9720 E-mail: chibe@mail.med.upenn.edu Website: http://chibe.upenn.edu

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