Technical and Scientific Basis
While the Program may appear relatively simple, it is actually a complex combination of human factors engineering, web technologies, software application development, and applied behavioral and social sciences that are specifically designed to overcome the issues that have prevented the traditional models from succeeding.
The following is a description of the concepts that both underpin and explain why the Program is effective, along with supporting studies and literature.
Human Factors Engineering - Human factors engineering is a foundation of the Program that has less to do with man-machine design (ergonomics), and more to do with how computers and software applications influence human behavior. This subspecialty of human factors engineering includes the study of human-computer interaction and cyberpsychology. This is an emerging field of study that is covered in Computers in Human Behavior a peer-reviewed journal dedicated to the subject.
Examples of this field include wearable technologies, telemedicine, artificial intelligence, and a host of software applications and devices design to educate, remind, and motivate people to improve their health behaviors.
Web-Technology and Software Development – The web-technology and software application development aspects of the program acknowledge that without the advent of computers and the Internet, the system would be impractical and ineffective. This applies to every facet of the program, to include:
1. the transmission of eligibility and claims data;
2. the user notifications and reminders of rewardable events;
3. the information therapy software applications;
4. the provider treatment guidelines;
5. the patient education library;
6. the transmission of rewards and payments;
7. website hosting;
8. the system databases;
9. the user support and services functions;
10. HIPAA and data security;
11. disaster recovery;
12. the quality assurance warning system; and
13. the analytical and reporting functions.
Behavioral and Social Sciences – A key to the Program’s effectiveness is the application of behavioral and social science (psychosocial) insights to motivate participants to action. These motivators include the following:
• behavioral economics (financial incentives)
• image and service psychology
• the KEMA response
• the Hawthorne effect
• promise-keeping psychology and guilt aversion
• Pavlovian conditioning
• loss aversion
Since no individual is likely to be inspired by all of these motivators in any given session, the Program is designed to employ all of them, with the expectation that at least one motivator will move a participant to action. What follows is a description of these motivators, supporting studies, and how they are applied in the Program.
Behavioral Economics – According to research in the area of behavioral economics, financial incentives are effective at achieving participant engagement and immediate behavior change, but have limitations when it comes to sustaining a desired behavior. Quoting from one such study:
financial incentives can change habitual health-related behaviors and help reduce health inequalities. However, their role in reducing disease burden is potentially limited given current evidence that effects dissipate beyond three months post-incentive removal
Another study noted that:
Offering incentives for completing behavior change programs may increase completion rates, but increased health improvement does not necessarily follow.
In the Program, the monetary incentives, referred to as “precision-guided financial rewards,” are intended to recruit providers and patients to the Program’s website, where the behavior-improvement psychosocial motivators of the Program take effect.
Classical (Pavlovian) Conditioning - Another lesson from behavioral science involves classical conditioning, made famous by Ivan Pavlov in the early twentieth century. Classical conditioning theory involves learning a new behavior via the process of association in which a desired response to a stimulus is immediately rewarded, and repeated until a habit (conditioned response) is formed.
In this context, the Program offers doctors and patients a financial reward shortly after each office visit when the parties respond to notifications by participating in the Program. So, the desired conditioned response is program participation, health education and treatment compliance. Since patients with chronic disease often have a high frequency of office visits, this process is repeated, which helps in the conditioning process.
It should be noted that the Program’s frequent stimulus-response-reward process differs from other types of wellness initiatives that may only occur once or twice a year, such as risk assessments and health screenings. Obviously, these types of programs will tend to be less effective at changing behavior because they cannot benefit from Pavlovian conditioning.
Notification and Reminder Psychology – Closely related to Pavlovian conditioning is the psychology of notifications and reminders. It teaches that there is both art and science to delivering effective notifications and reminders.
With the advent of smartphones, wearables, and other personal electronics, the art and science of notifying and reminding has taken on new meaning. In his article entitled The Psychology of Notifications, Twitter design researcher, Ximena Vengoechea states that effective notifications in the cyber-age must be well-timed and actionable.
The Program has employed these design principles in developing a variety of communication methods to inform, notify and remind providers and patients. These methods include emails, faxes, telephony, text messages, letters, worksite posters, and health fairs.
The messaging (content), timing, and sequencing of the Program’s communications have been honed over several years to achieve maximum participation and the “SMART” objectives, while minimizing annoyance. The Program also takes advantage of other psychologies to recruit users, such as loss aversion (refer to the following section) by means of the Program’s Second Chance Campaigns, final notices and expiration dates. These techniques have been found to add approximately 15% to initial patient participation (success) rates.
Loss Aversion – Another psychology related to behavioral economics that is manifested in the Program is called loss aversion. It refers to people's tendency to prefer avoiding losses to acquiring equivalent gains (i.e., it is better not to lose $5, than to find $5).
In the Program, the term used to describe a rewardable event is called an “opportunity.” There are time limits on how long providers and patients have to complete opportunities before they expire. A series of reminders, including a “Final Notice,” are sent that inform users that their opportunities will be lost if they fail to act before the deadline. There is a pronounced increase in participation when these reminders are mailed, that clearly illustrates the motivation impact of loss aversion.
Precision-Guided Financial Rewards – The Program combines these behavioral economics principles into a process the developers describe as “precision-guided financial rewards.” The term is intended to signify that the Program’s monetary incentives are purposely directed toward recruiting physicians and patients to participate in the Program. Once participants are online, the longer- lasting, non-monetary motivators are deployed to achieve sustained behavior improvement that solves the Triple Aim.
Types of Financial Rewards – The Program is designed to incorporate a full array of financial incentives, to include gift cards, lotteries and other items of monetary value.
According to a Medicaid study, the old adage that “cash is king” seems to hold true. Therefore, the Program typically offers cash refunds of the office visit co-payment, in the form of check payments, as the means of issuing financial incentives to participating providers and patients.
Doctor-Patient Mutual Accountability – Typically, the relationship that exists between doctors and patients is based on trust and respect. “Mutual accountability” taps into this unique relationship, motivating better performance and compliance that helps improve clinical and economic outcomes.
The Program accomplishes “mutual accountability” by offering financial rewards to both doctors and patients for accessing the Program’s website to declare or demonstrate their level of compliance, provided they agree to allow the other party to review their compliance declaration or demonstration. For physicians, compliance is to evidence-based treatment guidelines. For patients, compliance is to recommended treatments and healthy behaviors.
Since doctors and patients report their compliance to one another, and not to a third-party payer, this creates a check and balance that allows both parties the freedom to declare non-compliance, as long as they provide a reason for noncompliance that they are willing to share with the other party.
“Mutual Accountability” from the Provider’s Perspective - Medical providers are drawn to the profession to serve others. They are motivated intrinsically by a sense of duty to help their patients, and a sense of personal satisfaction when they meet their patients’ medical needs.
When providers prescribe information therapy, they experience the fulfillment of witnessing their patients become more competent in self-managing their health. This is an example of an intrinsic motivator associated with the Program.
Patient influence on physician behavior is an extrinsic motivator. The “mutual accountability” aspect of the Program deals with how patients influence physician behavior. While there is little research on this subject, there are studies that measure related motivators. One such study attempted to determine what influenced health professionals to engage in shared decision-making (SDM) with their patients.39 This study found that social pressure (subjective norm) was the most frequently cited influencer on provider behavior. To some degree, patients represent a portion of this social pressure.
It is often said that reputation is one of the most important assets a physician possesses. To build a positive reputation, doctors want their patients to perceive them as caring, service oriented and professionally competent. Therefore, when providers participate in the Program, they are demonstrating to their patients that they care and are service oriented.
While patients often lack the knowledge needed to judge clinical competency, the Program helps elevate their understanding so patients can better evaluate their providers’ performance.
In theory, when providers become aware that the Program is educating patients on evidence-based care, and then asking them to rate their physicians’ performance against that standard, providers are more motivated to adhere to such care, or provide patients with an explanation why such care is not appropriate. A case in point is the following quote voluntarily posted to the program’s website by a covered patient:
Our doctors [sic] level of treating us has improved with this valuable program.
There is also preliminary quantitative evidence to this effect, such as a decrease in defensive medicine associated with the introduction of the Program. This correlation requires more thorough examination.
The patient education aspect of the program also helps patients be more capable of engaging their physicians in shared decision-making. As a result, physicians will tend to treat knowledgeable patients more respectfully and less paternalistically.
Physician Influence on Patient Behavior – Studies have found that patients have better outcomes when their physicians are respectful, empathetic, and attentive. One such study determined that:
…patients who feel that their physicians treat them with respect and fairness, communicate well and engage with them outside of the office setting, were more likely to monitor their blood pressure, exercise five days a week and adhere to medication regimens, among other healthy behaviors.
Based on this study and other similar research, it is clear that physicians influence patient behavior. This subject is explored further in the following section.
“Mutual Accountability” from the Patient’s Perspective: The Hawthorne Effect – Physician influence on patient behavior is often characterized by a psychological phenomenon called the Hawthorne effect. This is described as a type of reactivity by an individual being observed by a person in authority. More precisely, the Hawthorne effect causes a person to improve his/her behavior or performance when that person perceives an increase in attention by superiors or persons in positions of authority.
Most patients assign a level of trust and respect to their physicians, especially when experiencing pain, fear, sadness, and uncertainty. In these moments of vulnerability, it is natural for patients to view their physicians as authority figures in matters of health and wellbeing, trusting in their doctors’ knowledge and skills to cure their illnesses, relieve their pain, and allay their fears. While many patients experience the Hawthorne effect anytime they are in the presence of their physician or anticipation thereof, it is at times of stress when it can be most pronounced.
In the Program, the act of patients agreeing to share their responses with their physicians invokes the Hawthorne effect.
There is little research on the potentially beneficial impact of the Hawthorne effect on patient behavior. To help fill this gap, the Program surveys patients in each information therapy session by asking the following questions:
1. On a scale from 1 to 10, with 10 being the most, how much does the knowledge that your physician has access to your questionnaire responses motivate you to improve your health literacy and health behaviors?
2. On a scale from 1 to 10, with 10 being the most, how important is it to you that your doctor is aware that you understand how to self-manage your health?
3. On a scale from 1 to 10, with 10 being the most, how important is it to you that your doctor is aware that you are trying to accomplish or are accomplishing health objectives?
These questions serve two purposes. First, they quantify the degree to which doctors influence patient behavior through the Program. Second, they convey a message to patients that doctors are included in the Program as a means to motivate patients to improve their health behaviors.
Health Literacy – The World Health Organization defines health literacy as:
…the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health Literacy means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment.
The WHO goes on to state that:
Health literacy is a stronger predictor of an individual’s health status than income, employment status, education level and racial or ethnic group.
Indeed, health literacy is one of the strongest, if not the strongest determinant of health status, life expectancy and healthcare costs.
Numerous studies establish the correlation between inadequate health literacy and higher rates of hospitalizations and the use of emergency room services. One such study found that:
Inadequate literacy was an independent risk factor for hospital admission [hospitalizations] ...
Another study found that:
Limited health literacy is a risk factor for potentially preventable ED [emergency room/department] visits, particularly those that result in hospital admission.
There are also a number of studies that establish the association of inadequate health literacy with higher healthcare costs.Perhaps the most significant of these studies was conducted by researchers at the Veterans Administration. They found that veterans with inadequate health literacy consumed nearly twice as much healthcare as veterans with adequate health literacy over a three-year period ($31,581 versus $17,033).
Not only is inadequate health literacy harmful and expensive, it is prevalent. In fact, only one in nine Americans has what is considered proficient health literacy.
This begs the question: if inadequate health literacy is harmful, expensive and prevalent, then why is it seemingly overlooked and undervalued? The best answer to this question is threefold:
1. The impacts of health literacy are not widely known.
2. It seems too simplistic a solution to such a complex problem.
3. Viable solutions to improve health literacy are nonexistent.
With regards to awareness, there is a growing interest across the country in health literacy. According to the Center for Disease Control and Prevention, there are eighteen states that have an organized health literacy initiative. While this is far from all fifty states, it is better than fifteen years ago, when there was essentially none. Further, October has been designated as National Health Literacy Month to help bring attention to this important topic.
Regarding the simplistic nature of health literacy, many highly educated decision-makers discount the importance of learning about health because they often cannot relate to being uninformed, or to lacking access to the information they need to know. This discounting stems from the so-called “curse of knowledge,” the cognitive bias that causes individuals to unknowingly assume that others have the background to understand what the they know. This can also lead some individuals to be unappreciative or exasperated that others don’t understand like they do.
These decision-makers similarly struggle to imagine how such an ostensibly simple solution could solve such a complex problem. They believe the solution must involve such advanced technologies as artificial intelligence (AI), telemedicine and the genome.
Professor Christensen, in his innovation book series, describes a “disruptive innovation” as one that:
1. Solves a complex or unsolvable challenge with a seemingly simple solution;
2. Is typically created by outsiders and entrepreneurs, rather than existing market-leaders;
3. Uses off-the-shelf components in a new and different way; and
4. Tends to be ahead of the market and often must wait until the market catches up.
In an article by the former CEO of Oklahoma’s largest health system, Integris, Stan Hupfeld implies that the Program is just such a “disruptive innovation,” concluding that, “We should not overlook the elegance of simplicity.”
With regards to health literacy solutions, the federal government and others are campaigning to translate written material containing medical jargon and numerical information, into words and pictures that everyone can understand. While a worthwhile endeavor, these campaigns often suggest that doctors “dumb-it-down” when communicating oral instruction, and practice the “speak-back” method by having their patients repeat their instructions. Doctors and patients complain that these methods are demeaning and undignified. Most population health experts agree that they are ineffective because, as studies indicate, the clinic setting is one of the worst places for educating patients. This is due to the fact that doctors tend to be in a hurry, and patients are emotionally distracted in the exam room. In fact, one study found that, on average, doctors interrupt their patients in the first eighteen (18) seconds of an encounter. Other studies found that patients understand and retain only 15% of what they are told in clinic, which results in only 50% compliance to treatment recommendations.
The Program solves these problems by providing patients with diagnosis-specific educational content, written at the fifth-grade level, at home, after each office visit. This allows patients to select the time and place that is most conducive to their comprehension. The Program takes it a step further by administering an open book test to allow patients to demonstrate and document their understanding of the content. Then the Program asks patients to declare their compliance to the treatment recommendations found in the educational content, or provide a reason for their non-compliance. Each of these steps help reinforce the learning experience and knowledge retention that are essential to patient empowerment, motivation and compliance.
Patient Education and the Knowledge-Empowerment-Motivation-Adherence Response – Elevating health literacy involves educating patients in a manner that improves their self-managing competency. One study reported that:
Interventions to improve self-care have shown improvements in self-efficacy, patient satisfaction, coping skills, and perceptions of social support. Significant clinical benefits have been seen from trials of self-management or lifestyle interventions across conditions such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis.
In another study, researchers note the following regarding patient education, empowerment and the psychosocial facets of managing a chronic disease:
This study indicated that patient empowerment is an effective approach to developing educational interventions for addressing the psychosocial aspects of living with diabetes. Furthermore, patient empowerment is conducive to improving blood glucose control. In an ideal setting, patient education would address equally blood glucose management and the psychosocial challenges of living with diabetes.
Empowerment as a means of motivation is a phenomenon well known in industrial psychology. Studies found that people are more motivated to accomplish a task when they know the “how” and “why,” are “entrusted” to perform the task, and when they are “rewarded and recognized” for accomplishment. The following excerpt from an economics research study speaks to this association between empowerment and performance.
The literature shows that factors such as empowerment and recognition increase employee motivation. If the empowerment and recognition of employees is increased, their motivation to work will also improve, as well as their accomplishments and the organizational performance.
A term used to describe the association of these psychosocial factors is the “knowledge-empowerment-motivation-adherence” response or KEMA. Simply stated, when people understand the “how” and “why,” they are more empowered and motivated to comply with recommended treatments, and, as a result, to adopt healthy behaviors. In fact, the World Health Organization’s health literacy definition (refer to Health Literacy section, above), encapsulates the key elements of the KEMA response, i.e., motivation, understanding, and empowerment.
Information Therapy – The Program achieves the KEMA response by incorporating a type of patient education called “information therapy.” First mentioned in the literature in 1994, it is broadly defined to mean “providing patients with the right information, at the right time, so they can make an informed decision about their health.”
The symbol for information therapy is Ix ®. It was originally registered by patient education content supplier, Healthwise, whose co-founders, Don Kemper and Molly Mettler, wrote the book entitled, Information Therapy: Prescribed Information as a Reimbursable Service.
The Program borrows the term “information therapy” to describe the process by which patients become educated as a result of doctors prescribing (or patients selecting) educational content relevant to the patient’s diagnosis for a given episode of care.
In the Program, the term “reward-induced information therapy” points to four additionally important factors that are key to its effectiveness:
1. doctor and patient financial rewards;
2. patient testing on the educational content;
3. patient declaration of compliance; and
4. a patient agreement to share their responses with their physicians
First, doctors and patients are both offered financial incentives to complete an information therapy session. As suggested by the aforementioned studies in behavioral economics, levels of doctor and patient participation in the Program would be inadequate without a monetary inducement. Therefore, the Program’s “precision-guided financial incentives” are directed toward ensuring there is adequate doctor and patient participation in the Program’s “learn-to-earn” feature to produce the desired results.
Second, patients are tested to confirm they have read the prescribed article and understood the article’s key points. Testing also provides a feedback loop to providers that confirms their patients know how to self-manage their health. This aspect of the Program plays a critical role in the Program’s effectiveness, but has been surprisingly absent from the delivery of medicine heretofore. In other words, this is the first time in medical history that patients are routinely tested to confirm they understand how to self-manage their health.
Third, patients are asked to declare their compliance with what they have learned or provide a reason for noncompliance. The impact of this act, described in the “Declaring Compliance and Keeping a Promise” section, below, also plays an essential role in the Program’s effectiveness.
Fourth, patients are asked to share their knowledge assessment and declaration of compliance, or reason for non-compliance, with their physicians. The psychosocial motivator associated with this act is described in the “’Mutual Accountability’ from the Patient’s Perspective: The Hawthorne Effect” section, above.
Like the other components of the Program’s reward-induced information therapy, having patients agree to share their responses with their doctor is a critical element of the Program that has never been routinely employed in the delivery of medicine.
Declaring Compliance and Keeping a Promise – As mentioned in the Program Description and Information Therapy sections, above, one of the more powerful motivating psychologies employed by the Program involves the act of doctors and patients declaring their compliance to treatment guidelines, then agreeing to allow the other party to have access to their declarations. In effect, this process involves making a promise that creates an obligation to oneself and to someone each party respects (doctor to patient, and patient to doctor). As a result, both intrinsic and extrinsic motivators are summoned.
In his “Why Do People Keep Their Promises? An Experimental Test of Two Explanations,” German researcher Christoph Vanberg, concludes that:
…promises induce emotional commitments to fulfill contractual obligations, perhaps based on a norm of promise keeping.
Vanberg references other studies that explain promise keeping based on the theory of “guilt aversion.” According to one of these studies, guilt is “based on the desire to avoid taking actions that let down another person’s expectations.”
Whether it is a sense of obligation, guilt aversion, or something more intrinsic, such as setting a personal goal, the act of declaring compliance in the Program invokes motivators that are well documented in the literature.
The Trilateral Health Accountability Model – The Program combines all the concepts put forth in the supporting studies and literature to solve the Triple/Quadruple Aim in a full and normally distributed population—i.e., not in an isolated or disease-specific subset of a population. This is a key distinction that defines a true population health solution. It also represents the greatest challenge to solve. The Program’s patented process is designed to do just that. It is called the Trilateral Health Accountability Model® or THAM.
Content taken from the 2018 MedEncentive Study: 'Analysis of the cost containment capabilities of the MedEncentive Program in normally distributed employee health plans;' Studies that support the theories put forth are cited throughout the 2018 MedEncentive Study