Hospital Impact—Behavioral economics and big data may improve health and reduce healthcare costs

Organizations that want to reduce healthcare costs must first identify those drivers that are preventable and then determine the optimal path to avoid them. For lifestyle-related diseases like Type 2 diabetes, health promotion and lifestyle change programs present a real opportunity to lower healthcare costs while improving people’s health outcomes and care experience—all goals of the Institute for Healthcare Improvement’s Triple Aim.

In Iceland’s capital, Reykjavik, a combination of behavioral economics, big data and mobile technology is a promising way forward to identify individuals at increased risk of lifestyle-related diseases and reverse their condition.

What is behavioral economics? It combines lessons from psychology and economics to consider how people behaveas opposed to how they would behave if they were perfectly rational, with unlimited willpower, and solely acting out of self-interest. It considers how people are influenced by their emotions, identity, environment and the framing of information.

Behavioral economics can be applied to the prevention and management of diabetes, a disease that now costs an estimated $825 billion each year globally. A significant part of the economic burden stems from the number of people affected. About 422 million people have the disease, which equates to about 8.5% of the world’s population. In Iceland, where the population tends to be more physically active than the norm, the rate is 6.1%. However, it is experiencing an upward trend.

Because Type 2 diabetes develops slowly over months and years, the good news is the disease can often be delayed, prevented or even reversed. More than 1 in 3 adults are prediabetic—at higher risk for type 2 diabetes and cardiovascular disease—but a structured lifestyle change program focused on diet and physical activity can be an effective formula for achieving and maintaining a healthy weight and normal blood sugar level.

Large clinical trials, including the Centers for Disease Control and Prevention’s National Diabetes Prevention Program, have shown this type of program can cut the risk of progression from prediabetes to type 2 diabetes.

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As a physician who has worked with thousands of patients with lifestyle diseases, I recognize that messages of behavior change—eating right, exercising more and managing stress—do not so easily translate to everyday life. People have priorities that demand their time and attention, from managing a career to raising a family, that often relegate lifestyle choices to an afterthought.

In addition, adult health literacy is a challenge, and many people may have a low motivation for lifestyle change until a medical episode brings new perspective to the effects of unhealthy habits. As the industry looks to combat the impact of diabetes and help people engage in their healthcare, two dynamics have emerged to encourage prevention efforts.

First, we are developing a better understanding for how individuals make their lifestyle choices, particularly when a behavioral economics model is applied. Lessons from behavioral economics can support public health because they help us guide people toward better choices. To date, the more traditional, “rational" appeals—such as black-and-white nutrition labels on the back of a food packages—have fallen short in steering people toward healthier habits. Since the more “emotional” part of our brain is responsible for most of our lifestyle choices, targeting decision-making with emotional appeals—such as games, instant gratification and rewards—can more effectively activate the triggers that motivate people.

That dovetails well with the fact that mobile devices are approaching ubiquity, providing a direct channel for preventive care. Not only are smartphones widely distributed, but people carry them at all times, spending several hours per day using apps that often deliver powerful emotional triggers in the brain. Mobile devices can increase provider-patient interaction for lifestyle interventions, as well as offer opportunities for primary prevention.

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Combining behavioral economics with technology has applications for both providers and employers. By incorporating a digital layer to traditional lifestyle programs, clinicians and coaches can complement in-person sessions with tools that help people manage their health anywhere and open channels for support along their journey. Employers can integrate similar methods into workplace initiatives to promote employee wellness and reduce the risk lifestyle-related disease among the workforce.

One example of how this approach has been successfully deployed is in Reykjavik. Earlier this year, more than 2,000 municipal employees across the country’s capital participated in the first step of a new workplace wellness program. Using a health engagement platform on their smartphones, employees took part in health challenges in three focus areas.

The first was nutrition, enabling participants to set goals for consuming healthy meals, practicing mindful eating and avoiding sugary foods. The second was exercise, allowing participants to count steps, log workouts and record activities like household chores. The last was stress reduction, such as relaxation, mindfulness and meditation exercises.

Over the course of three weeks, employees who took part in the initiative completed more than 500,000 health-improving activities, including stair-walking the equivalent of 100 trips up Mount Everest.

In addition to the health advantages, the “Reykjavik Health Games” encouraged competition and teamwork across the organization as participants worked to earn the most points for their group or department. Further motivating participants, the points they were earning accumulated towards a charity water donation, which the City of Reykjavik provided to an organization focused on helping children in need. 

Participants were also offered a simple, seven-question prediabetes screening through their phone as part of the initiative. Of the employees who completed the questionnaire, more than 200 were determined to be at increased risk for diabetes and were referred to a 16-week, structured lifestyle change program administered through a digital platform in association with a local healthcare provider.

This approach can support efforts by insurers, providers and employers to reduce health costs. The Agency for Healthcare Research and Quality found diabetes with complications ranked at the top for hospitalizations covered by Medicare and Medicaid and those who were uninsured. Reducing the number of diabetes patients requiring inpatient admissions can help lower this expenditure.

Second, diabetes prevention programs that can effectively motivate their participants to lose weight and adhere to their program can improve the health of their populations and achieve quality metrics for reimbursement.

While cutting healthcare costs is a daunting challenge on its face, lifestyle-related diseases present a clear opportunity for progress. Helping people recognize their potential risk for diabetes, empowering them to make lifestyle change and engaging the triggers that motivate their behaviors and are the keys to keeping them healthy and out of the hospital.

Tryggvi Thorgeirsson, M.D., is a guest lecturer at Harvard University on applying behavioral economics for lifestyle interventions and a guest lecturer at MIT on data-driven health. He is also the co-founder/CEO of SidekickHealth, a digital health company.