Helping people change their behavior 'is the work of our century'

(First of a three-part series: Channeling Choice)

Mary Lowery, diagnosed five years ago with congestive heart failure, always shopped carefully for groceries on the small paycheck she brought home from a security firm. She scrutinized her options, carefully reading the labels as she combed the aisles of the local Wal-Mart.

She was shopping for price. She ignored the sodium that would cause further damage to her heart.

“The only thing I ever did on the (nutrition) labels was see how many servings you could get out of a can or a box, and that would tell me if I would need to get two boxes or one box,” she said. As a diabetic, she also scanned labels for sugar. “I never paid attention to the salt content.”

Lowery, with a family to feed, little money and no health insurance, always bought the cheapest foods that would not spoil. They were often high-salt, processed foods. Doctors had advised Lowery to cut back on salt. Sodium causes the body to retain fluid that can strain a weakened heart. So Lowery switched to a low-sodium type of salt, but with little information about her disease, little else changed. “I was still eating all my junk food that I wanted and wasn't following any type of diet,” she said.

Fluid eventually built up in her body. She swelled to 384 pounds. She couldn't walk to her car without losing her breath. She slept sitting up because lying down led to uncontrolled coughing.

That's when Lowery's merry-go-round through the Carolinas Medical Center in Lincolnton, N.C., began. In May, she arrived at the emergency room complaining of “suffocating.” She remained in the hospital for 11 days. During that stay, she became the first patient on the receiving end of the hospital's campaign to end repeat visits to the hospital. Poorly treated congestive heart failure is one of the major reasons patients return to the hospital less than a month after leaving.

While at the hospital, a team of cardiologists, nurses, pharmacists and social workers coordinated Lowery's care. A heart failure specialist met with her daily so she would understand the disease and her medication. After discharge, the education continued with weekly clinic visits. A team of dietitians, pharmacists and advanced-care practitioners told her what she could eat and drink and what symptoms to watch out for.

But what happened after Lowery left the hospital underscores the challenge facing healthcare providers and, for that matter, anyone who has struggled to change their behavior. Within 34 days, she was back in the hospital. “I resisted it at first,” Lowery said, “because I'd slipped back a little bit and didn't really pay that much attention to it.” She stayed 13 days.

Lowery's setback amid the fledgling effort at Carolinas HealthCare System points to one of the central issues facing healthcare system officials as the nation struggles to coordinate care to improve health and slow the growth in U.S. healthcare spending.

The daily decisions patients make outside the reach of hospitals, clinics and physician offices on what to eat; whether to exercise or quit smoking; and whether they take their medicines profoundly affect their health and how they will respond to medical intervention, be it therapy to maintain health or complex disease management to prevent rehospitalization.

That's why a growing number of health systems, doctors and insurers are looking to expand the reach of healthcare from the hospital and pharmacy into patients' homes and lives. Their goal is to keep patients with chronic conditions—which today includes nearly half of U.S. adults—healthy enough to avoid the emergency room or hospital.

Many are investing heavily in education and social work to reach beyond patients' immediate clinical needs. Health systems such as Carolinas HealthCare and fledgling accountable care organizations—new healthcare networks that stand to profit or lose based on the quality and cost of patients' care—are pouring resources into tackling barriers of income, transportation and health literacy to encourage healthy choices among the chronically ill.

But that might not be enough. Resistance to change has led providers and insurers to delve into the fields of psychology and economics in their search for more effective and efficient interventions that can overcome the powerful societal forces that undermine health, whether from inadequate income or a lifetime of lousy habits.

These new interventions pair strategies from the emerging field of patient engagement—which builds on a person's existing resources and knowledge—with behavioral economics, which seeks to understand why people make illogical choices. The goal is to develop incentives that nudge the chronically ill to make decisions that promote personal health.

The obstacles to changing behavior are significant and most of these new approaches are only beginning to take shape. “It's not an easy fix,” said Jessica Greene, a nursing professor and researcher on patient engagement at George Washington University. “Anyone who has tried to lose 10 pounds knows how hard it is.”

This first installment of Modern Healthcare's Channeling Choice series looks at the decisions people make that affect their health, the factors that influence those choices, and the challenges facing the healthcare industry as it seeks to sway those decisions. The next part will investigate how patient choice contributes to underuse or overuse of prescriptions and other therapies. The final article will offer profiles of patients grappling with three powerful influences on decisionmaking: money, health literacy and emotion.

Chronic diseases such as diabetes and heart disease, which are linked to smoking, poor eating and exercise habits, are among the most common and costly contributors to the nation's rising healthcare costs. Adults with chronic diseases account for 75% of the nation's healthcare spending, according to the Robert Wood Johnson Foundation. Two-thirds of the rise in healthcare spending is attributable to the increased prevalence of chronic disease and new technology to fight disease, according to the Partnership to Fight Chronic Disease.

While genetics plays a role, economic stress, cigarettes, too many calories, too much salt and too little exercise are major contributors to the rising cost of care. Spending for hospital care, trips to the emergency room, clinic visits, prescriptions and other medical intervention totaled $116.3 billion for heart disease and $55 billion for diabetes in 2011.

To lower those costs, experts say healthcare providers need to focus their attention on what people do before they show up in the ER. The strategy is what physicians David Asch and Kevin Volpp and healthcare executive Ralph Muller described in the New England Journal of Medicine as “watching over the 5,000 hours,” or the time we spend each year awake, active and outside the doctor's office.

WellPoint, one of the nation's largest insurers, and Fairview Health Services, a major provider system based in Minneapolis, have started surveying the skills, knowledge and confidence patients bring to disease management. The survey, developed by Judith Hibbard at the University of Oregon and marketed by a company she founded, stratifies patients by how likely they will be to actively manage their health.

Research published in February in Health Affairs suggested more engagement is associated with better health and lower costs. “Helping patients develop confidence and skills is part of the job,” said Hibbard, a health policy professor.

Not everyone has the same choices. Like Lowery, many cannot afford fresh vegetables and other perishable foods. The trade-offs between paying the rent and keeping up with their prescriptions and regular primary-care visits may be too great.

Lowery also did not seek routine medical care after her initial diagnosis. “I tend to ignore my health a lot because I didn't have insurance,” she said. “So going to a regular doctor all the time really didn't happen.”

Others don't know how to change or may be unwilling to try after several failed attempts. Some don't see why change is important because they lack information about the illness or its urgency.

After Lowery's second discharge from the hospital in July, Carolinas HealthCare continued to pour resources into her post-acute care. A social worker helped her to enroll for food stamps. She began to call the dietitian.

It started to work. She lost more than 100 pounds in excess fluid. “My habits are definitely changing,” she said. “If I went out driving someplace, the first place I would stop would be either Hardee's or McDonald's. Because I always have to pass one of those and it's like my car would automatically steer in there and hit the dollar menu. … I just don't stop for those places anymore,” she said.

Yet in September, she showed up at the ER again. Thinking she had a kidney stone, she was suffering from another bout of fluid buildup around her heart and lungs. The result: Another five days in the hospital.

Carolinas began experimenting with strategies to keep patients like Lowery out of the hospital about the same time that Medicare began penalizing hospitals that had excessive rates of heart failure patients returning to the hospital within 30 days.

Heart failure patients are often rehospitalized because they fail to adhere to medications or prescribed diets and many don't recognize worsening symptoms, said Sanjeev Gulati, director of the heart failure program for the Carolinas' Sanger Heart & Vascular Institute. “There are multiple factors, but a lot of it tends to be education related,” he said.

The system developed a program to help patients learn in their homes shortly after discharge. For those who cannot travel to Charlotte or a local hospital, it starts with a visit from home health nurse like Pati Cooper. She reviews medication, draws blood and checks breathing. Her tool kit includes a laptop so she and patients can consult virtually with specialists.

Cooper also visits the patient's kitchen. “We start pulling cans and boxes out and things out of their refrigerator and talk about the things that they eat,” she said. She tells patients the choice is theirs, and so are the consequences. “I am not your momma,” Cooper said. “I can't tell you what to do.”

Those efforts turned in some notable early results. The system's main hospital went from a 17.5% 30-day readmission rate in 2012—the year the program started—to 10.1% through May of this year.

But others are looking beyond education and support to a growing body of social science research that analyzes how people evaluate risk and make judgments.

Blue Cross and Blue Shield of Massachusetts, the state's largest insurer, is launching a lottery for overweight municipal workers as an incentive to shed pounds. The lottery, which will open in February, is based on recent studies by Dr. Kevin Volpp and others that showed lotteries are more effective than traditional weight-loss programs, which rely on weight checks.

The lottery is drawn from research that suggests we anticipate regret and seek to avoid it. “You don't like to regret having not done something, and then wishing you had,” said Cathy Hartman, vice president of prevention and wellness for the Massachusetts Blues.

One study of obese dieters given a lottery incentive led to participants losing 13 pounds on average within four months. Everyone was enrolled in the lottery, but only participants who lost weight could claim the $10 or $100 prizes. A comparison group of dieters with no incentive lost 4 pounds during the same period.

“It's a bit of an inducement,” said William Berry. Berry is a participant in separate research by Asch—executive director of the University of Pennsylvania's Center for Health Care Innovation—that is testing use of lotteries to promote drug adherence. Berry has won $115 in three months. Daily phone calls notify him of lottery results. “I know if I don't do it, I am definitely not going to win,” he said.

Oregon last year started using what behavioral economics researchers call “loss aversion” to achieve greater healthcare cost savings among its employees, said Joan Kapowich, a nurse and administrator for the Oregon Public Employees' Benefit Board and the Oregon Educators Benefit Board. The desire to avoid loss is another motivator identified by behavioral economics research. The state told its employees they would see $17.50 less per monthly paycheck in 2012 if they did not take a health survey and complete two healthy activities. About 85% enrolled and 70% met the requirements.

Kapowich credited the results, combined with a growing number of increasingly sophisticated health plan incentives, for the fact that employees will see no increase in premiums in January. Oregon employee premiums have increased 5% annually in recent years, which would have totaled $39.2 million in 2014.

The threat of reduced paychecks can backfire, though. Employee protests forced Penn State University to drop its plan to charge employees up to $1,200 a year for failing to complete a wellness profile and biometric screening.

Oregon faced a backlash as well. After employees complained, the state switched to a bonus—an extra $17.50 a month if they joined the program. Enrollment in the initiative dipped to 77% last January even though employees who opted out also faced a higher health plan deductible.

The nation's largest insurer, UnitedHealth Group, has adopted a loss-aversion strategy for its own employees. “People hate to lose stuff,” said Dr. Lewis Sandy, senior vice president of clinical advancement for UnitedHealth Group. “They're much more motivated by avoiding losses than by getting gains.” Insurers told employees a $600 incentive was theirs to lose, another behavioral economics strategy known as “framing.”

WellPoint, meanwhile, uses framing to encourage subscribers to switch to less expensive drugs. WellPoint contacts patients with an estimate of the potential savings, but describes the amount as money that could be used for vacation or other expenses, said Dan Newton, vice president of product and solutions development and behavioral economics for the insurer.

Providers and insurers are also deploying new tools drawn from psychology to target their intervention programs—all with the aim of personalizing their approach to influencing patient choices. WellPoint, for instance, this year began using a brief survey to determine how engaged or overwhelmed patients feel after being diagnosed with cancer. The two-question survey was added to an automated call about cancer resources. If the answers indicated the patient might be struggling, their calls were immediately transferred to WellPoint nurses or health educators who walked them through their treatment options.

For the 500,000 new enrollees added to its Medicare Advantage plan this year, WellPoint added six patient activation questions developed by the University of Oregon's Hibbard. The company plans to analyze answers to determine who is at greatest risk of hospitalization and might benefit from swift intervention.

Fairview Health Services began to ask patients in 2009 to complete a 13-question version of the measure. Now the system is using the results to identify which of 20,000 diabetic patients may benefit most from aggressive coaching and education.

How best to respond to a low score is still uncertain, but the engagement measure provides Fairview with an indication of who might be overwhelmed by the complicated regimens and diets they must adopt. “If we go in there and start prescribing more things, do more interventions, it just makes all that worse,” said Dr. Lynne Fiscus, the lead physician for two Fairview primary-care clinics and an urgent-care center.

For now, she starts by building up patients' confidence so that they can manage the disease outside of the four hours a year they visit the doctor. It's a prescription for changing behavior, not delivering a prescription, which is new for physicians trained to have all the answers.

“My role is not to be the expert or to cure, but to really help you develop the tools you need to manage this chronic illness over the course of your lifetime,” Fiscus said. It's also more effective at “helping people actually change their behavior, which is the work of our century.”

Follow Melanie Evans on Twitter: @MHmevans