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 Newsletter

 

October 2013

In This Issue
Authors Say Impact of ACA Health Incentives Will Depend on Design
Penn Study Finds Nighttime Intensivist Staffing Doesn't Boost Patient Outcomes
Research Spotlight: Adam Grant, PhD
Musings About Behavioral Economics
New Initiatives

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Recent Publications

 

Provider Dismissal Policies and Clustering of Vaccine-hesitant Families: An Agent-Based Modeling Approach. 
Buttenheim AM, Cherng ST, Asch DA. 
 

An Empirical Derivation of the Optimal Time Interval for Defining ICU Readmissions.

Brown SE, Ratcliffe SJ, Halpern SD. 

Med Care. 2013. 51(8):706-14.  
 
Supplementing Menu Labeling with Calorie Recommendations to Test for Facilitation Effects.  
Downs JS, Wisdom J, Wansink B, Loewenstein G. 

 

Mortality Among Patients Admitted to Strained Intensive Care Units.
Gabler NB, Ratcliffe SJ, Wagner J, Asch DA, Rubenfeld GD, Angus DC, Halpern SD. 
 
Public Preferences About Secondary Uses of Electronic Health Information.
Grande D, Mitra N, Shah A, Wan F, Asch DA. 

Does Study Partner Type Impact the Rate of Alzheimer's Disease Progression?
Grill JD, Zhou Y, Karlawish J, Elashoff D.

Turning Wrong Into Right: The 2013 Lung Allocation Controversy. 
Halpern SD. 

Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition.
Kangovi S, Barg FK, Carter T, Levy K, Sellman J, Long JA, Grande D.  
 
Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. 
Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. 
 
A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit. 
Kerlin MP, Small DS, Cooney E, Fuchs BD, Bellini LM, Mikkelsen ME, Schweickert WD, Bakhru RN, Gabler NB, Harhay MO, Hansen-Flaschen J, Halpern SD.  
 
Children's Objective Physical Activity by Location: Why the Neighborhood Matters.  
Kneeshaw-Price S, Saelens BE, Sallis JF, Glanz K, Frank LD, Kerr J, Hannon PA, Grembowski DE, Chan K CG, Cain KL. 
 
Behavioral Economics Holds Potential to Deliver Better Results for Patients, Insurers, and Employers.
Loewenstein G, Asch DA, Volpp KG. 
 
Consumers' Misunderstanding of Health Insurance. 
Loewenstein G, Friedman JY, McGill B, Ahmad S, Linck S, Sinkula S, Beshears J, Choi JJ, Kolstad J, Laibson D, Madrian BC, List JA, Volpp KG.  
 
Public Reporting of Hospital-Acquired Infections is Not Associated with Improved Processes or Outcomes. 
Linkin DR, Fishman NO, Shea JA, Yang W, Cary MS, Lautenbach E. 
 
Smoking, Obesity, Health Insurance, and Health Incentives in the Affordable Care Act. 
 
Are Physician Recommendations for BRCA1/2 Testing in Patients with Breast Cancer Appropriate? A Population-Based Study. 
McCarthy AM, Bristol M, Fredricks T, Wilkins L, Roelfsema I, Liao K, Shea JA, Groeneveld P, Domchek SM, Armstrong K. 
 
How do we Reward the Kind of Care We Want?  
Mehta SJ, Asch DA.  
 
How to Make a Successful Transition From Fellowship to Faculty in an Academic Medical Center. 
Mehta SJ, Forde KA. 

Gastroenterology. 2013. Epub ahead of print.

 

Teaching hospital financial status and patient outcomes following ACGME duty hour reform.   

Navathe AS, Silber JH, Small DS, Rosen AK,Romano PS,Even-Shoshan O, Wang Y, Zhu J, Halenar MJ, Volpp KG.

Health Services Research. 2013. 48(2,1).   

  

Estimating the Staffing Infrastructure for a Patient-Centered Medical Home.

Patel MS, Arron MJ, Sinsky TA, Green EH, Baker DW, Bowen JL, Day S.
Am J Manag Care. 2013. 19(6):509-16. 
 

 

The Importance of Clinical Severity in the Measurement of Hospital Readmission Rates for Medicare Beneficiaries, 1997-2007.

Press MJ, Scanlon DP, Navathe AS, Zhu J, Chen W, Mittler JN, Volpp KG.
Med Care Res Rev. 2013. Epub ahead of print.

 

Crowdsourcing-Harnessing the Masses to Advance Health and Medicine, a Systematic Review. 
Ranard BL, Ha YP, Meisel ZF, Asch DA, Hill SS, Becker LB, Seymour AK, Merchant RM. 
 
Taking Our Medicine-Improving Adherence in the Accountability Era. 
Rosenbaum L, Shrank WH. 
 
Development of a Pedestrian Audit Tool to Assess Rural Neighborhood Walkability. 
Scanlin K, Haardoerfer R, Kegler MC, Glanz K. 

Maintenance of Smoking Cessation in the Postpartum Period: Which Interventions Work Best in the Long-Term?  
Su A, Buttenheim AM. 
Matern Child Health J. 2013. Epub ahead of print. 
 
Innovating in Health Delivery: The Penn Medicine innovation Tournament. 
Terwiesch C, Mehta SJ, Volpp KG. 
 
Making the RCT More Useful for Innovation with Evidence-based Evolutionary Testing. 
Volpp KG, Terwiesch C, Troxel AB, Mehta S, Asch DA.
 
Parental Vaccine Concerns, Information Source, and Choice of Alternative Immunization Schedules.
Wheeler M, Buttenheim AM.

ICU Occupancy and Mechanical Ventilator Use in the United States. 
Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD.  

Awards

 

Scott Halpern

Upcoming Events

 

CHIBE Work in Progress Seminars

Georgetown University:
"The Over-Prescription of Disclosure in Managing Conflicts of Interest"
10/3 - 12:00 pm
Blockley Hall 11th Floor Conference Room

Sean Hennessy, PharmD, PhD, UPENN PSOM: "TBD"
10/24 - 12:00 pm
Colonial Penn Center Faculty Lounge
 
Julie Downs, PhD, Carnegie Mellon University: "TBD"
11/14 - 12:00 pm
Blockley Hall 11th Floor Conference Room

Tanja Kral, PhD, UPENN SON: "TBD"
12/12 - 12:00 pm
Colonial Penn Center Chestnut Room

10/7 - 10/8
Congress Hall
Cape May, NJ

Contact Us
 
Mailing Address:
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423 Guardian Drive
Philadelphia, PA 19104-6021
 
Telephone:
215-746-5873
 
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Dear Colleague,

 

We hope you had a great summer! Our October issue of the CHIBE newsletter features an interview with CHIBE faculty member and Wharton professor Adam Grant, author of a recent New York Times bestseller: Give and Take: A Revolutionary Approach to Success, which is based on his research in organizational psychology. He discusses the field of organizational psychology and what inspires his research.

 

This issue also highlights some of the key design issues around Section 2705 of the Affordable Care Act, which markedly increases the ability of employers to use outcome-based incentives.  The impact of these programs may depend to a significant degree on how much they use insights from behavioral economics; standard premium adjustment may not change behavior much and thereby could simply lead to higher-risk people paying more, as expressed by CHIBE researchers, Kevin Volpp and Harald Schmidt in the July issue of JAMA.

 

Also featured in this issue is a study conduced by Scott Halpern that was published in the June issue of NEJM. While not behavioral economics, this is an example of the high impact scholarship CHIBE researchers do in areas related more broadly to health care improvement. The study, the first of its kind, found that placing board-certified intensive care unit specialists ("intensivists")  on hospital duty at night didn't improve ICU patient outcomes. The extra costs to society of nighttime intensivist staffing are millions of dollars a year per hospital, raising interesting questions as to whether this staffing model makes sense.

 

In our "Musings" column, Helen Darling discusses employers three biggest challenges to providing affordable, quality health benefits and improving health. She describes some potential approaches drawing on behavioral economics and  behavioral sciences more broadly that can help reduce risk, harm and wasted expenses, as well as improve health.

 

We hope you enjoy reading this issue of the CHIBE newsletter!

 

Sincerely,

 

Kevin Volpp, Director

 

Scott Halpern, Deputy Director

Authors Say Impact of ACA Health Incentives Will Depend on Design


The Patient Protection and Affordable Care Act reduces the degree to which insurers can charge higher premiums or deny health coverage to individuals with preexisting medical conditions.  In an effort to encourage the use of benefit design to improve health, however, the health reform law bolsters employers' ability to tie workers' premiums or co-payments to factors such as tobacco use or body mass index in the context of such initiatives.

 

This approach has the potential to improve health but there are a number of important considerations that will likely impact the degree to which health is improved, according to an opinion piece published in July in the Journal of the American Medical Association. Effective program designs that incorporate insights from behavioral economics in ways that account for the frequency of feedback, the saliency of rewards, and that consider elements like the fact that people try harder when they are near a goal could be successful in improving health whereas incentive designs that use standard economic approaches like adjusting premiums once a year might not be all that effective at changing health behavior. The authors expressed concern that ineffective programs could financially harm higher-risk people and undercut the ACA's efforts to uncouple health status and insurance costs. 

 

Kevin Volpp

"Given the increasing interest in health incentives, more evidence of their effects is needed," a Northeastern University law professor and two University of Pennsylvania researchers wrote in the article, noting that regulators have acknowledged a lack of sufficient evidence to assess workplace wellness programs' influence on health outcomes and costs.  In addition, programs that have been evaluated have tended to use standard economics and it is only recently that behavioral economics has begun to influence program design.

 

"Careful design, testing and evaluation will be essential to ensuring that the potential for both private and public incentive programs to improve the health of insured populations is realized," said the article, written by Prof. Kristin Madison, Ph.D., J.D., of Northeastern's School of Law, CHIBE research associate Harald Schmidt, Ph.D., assistant professor in the Department of Medical Ethics and Health Policy at Penn's Perelman School of Medicine, and CHIBE Director, Kevin Volpp, M.D., Ph.D.

 

If incentive programs prompt people to reduce their health risks, health status could improve for large parts of the population, but if poorly designed programs do little to change behavior or improve health outcomes, "higher-risk individuals may be left in a worse financial position," they wrote.

 

Harald Schmidt

Federal law already barred employers from basing individual workers' group health eligibility or premiums on health status, but allowed them to implement disease-prevention programs that tie financial incentives or surcharges to smoking or weight.  

 

The ACA builds on that exception by supporting the use of outcome-based health incentives in both private and government insurance plans.  In the workplace, the ACA raises the ceiling on incentives or surcharges that employers may use in wellness programs as of Jan. 1, 2014 to as much as 50% of total premiums, if the programs include smoking.  

 

ACA rules require employer plans that base rewards on health outcomes to provide a "reasonable alternative standard" for qualifying for the reward. Small-group plans may vary premiums based on tobacco use, but only in the context of wellness programs that allow smokers to cut their premiums to non-smoker levels by enrolling in a smoking-cessation program or a reasonable alternative. Individual-market premiums can be higher for smokers, even without incentive programs.

 

Kristin Madison

The fact that health incentive efforts under the ACA vary by coverage type reflects uncertainty about the effectiveness of such programs, the authors said.

 

Madison noted in an interview that while the ACA allows employers to be more aggressive in using wellness programs, it also offers protections for employees. It remains to be seen whether the regulations help people achieve their health goals or give them an easy way out, she said.

 

 "We know that incentives change behavior," said Madison, noting randomized control trials showing that people respond to financial incentives to quit smoking or lose weight. "It really matters how those incentives are structured," she said.
 
 

- Dinah Wisenberg Brin

Penn Study Finds Nighttime Intensivist Staffing Doesn't Boost Patient Outcomes

   
Scott Halpern

In U.S. teaching hospitals, intensive care units (ICUs) have typically only been staffed at night by physicians at various stages of training. By contrast, nearly three quarters of European ICUs use intensivists - physicians board-certified in critical care medicine - at night. Because this would seem to improve patient outcomes, given intensivists' greater experience and presumed ability to expedite decision making and reduce medical errors, increasing numbers of ICUs in the United States have added intensivists to their nighttime staffs. While research suggests generally that intensivists improve ICU patient outcomes, limited observational studies on the medical value of costly nighttime intensivist staffing have produced mixed results, and no definitive evidence on this has been available to date.

 

To shed light on the matter, a team of University of Pennsylvania researchers led by CHIBE Deputy Director Scott Halpern, M.D., Ph.D. undertook a one-year, randomized trial and found no advantage to nighttime intensivist staffing. Results of the trial, conducted at the 24-bed Medical ICU (MICU) at the Hospital of the University of Pennsylvania, were published in June in The New England Journal of Medicine. 

 

"We were unable to identify any benefits whatsoever to having intensivists in the hospital at night," said Halpern, assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy at the Perelman School of Medicine. Halpern noted, though, that the researchers compared nighttime intensivist staffing periods to control periods in which well-trained residents staffed the hospital at night and had telephone access to the daytime intensivists who knew many of the patients well.

 

The researchers randomly assigned blocks of seven straight nights to either the intensivist-staffing strategy or the control approach -- an analysis that included nearly 1,600 patients. The primary outcome studied was the length of patient stay in the ICU. The researchers also measured ICU and hospital mortality, discharge disposition, and ICU readmission rates.

 

On "intervention" nights, one intensivist was on duty in the MICU from 7 p.m. to 7 a.m., and responsible for all patients. On control nights, two daytime intensivists and critical care fellows, available by phone to in-hospital residents and nurses, maintained primary responsibility for patients.

 

Nighttime intensivist staffing in the hospital didn't have a significant effect on length of ICU stay, ICU mortality, or any other endpoint, the study found. The conclusion: In a U.S. academic medical ICU, placing intensivists on hospital duty at night didn't improve patient outcomes.

 

"We were surprised that there was absolutely no benefit that could be identified," Halpern said. "Although there are clear benefits to being cared for in an ICU with such trained intensivists, there are probably diminishing marginal returns beyond a certain 'dose' of such experts," he added.

 

Halpern said the extra costs to society of nighttime intensivist staffing is on the order of millions of dollars a year per hospital. However, hospitals can recoup some or all of these costs through augmented billing, passing the bill on to private or government insurers. Perhaps for this reason, coupled with the logical assumption that intensivists would have improved outcomes, one-third of U.S. academic ICUs now use in-hospital intensivist staffing at night.

 

Halpern noted that the study didn't measure all outcomes that may be important to patients, families, payors and policy makers, such as patient satisfaction, nursing evaluation of quality of care, and physician burnout rates. "All of these are issues that we are currently in the process of evaluating," he said. Nonetheless, the study is already influencing hospitals' decisions. As a direct result of the study, the Hospital of the University of Pennsylvania reversed its plans to roll out nighttime intensivists in the MICU, and several peer institutions are using the study to inform their own related decisions.

 

Researchers should study next whether there is a benefit to nighttime intensivist staffing at other types of institutions, such as community hospitals with different staffing regimens, Halpern said. On this question, the jury is still out, with one large observational study showing a benefit to having nighttime intensivists in such ICUs, and another study showing no such benefit.

 

This article is based on the following study: Kerlin MP, Small DS, Cooney E, Fuchs BD, Bellini LM, Mikkelsen ME, Schweickert WD, Bakhru RN, Gabler NB, Harhay MO, Hansen-Flaschen J, Halpern SD. A randomized trial of nighttime physician staffing in an intensive care unit.  N Engl J Med. 2013. 368(23):2201-9.

 

- Dinah Wisenberg Brin

Research Spotlight: Adam Grant, PhD  
Adam Grant
 
Adam Grant, Ph.D., is a teacher, researcher, and tenured management professor at Wharton. In his work, Dr. Grant explores altruism and prosocial motivation, meaningful work, job design, initiative and proactivity, leadership, and employee well-being and burnout. His recently published book, Give and Take: A Revolutionary Approach to Success distills academic research on prosocial motivation for mainstream and business audiences. 

 

How did you become interested in organizational psychology?

 

When I was a springboard diver I had to hurl myself off into the air to do somersaults and twists, and it was sometimes terrifying. I was able to do it and coach others to do it using psychology, which fascinated me. I have always been very curious about what drives people to think, feel, and act in all the ways that they do. I started reading academic psychology journals and popular psychology books to tap into the accumulated knowledge about human behavior. In college I was inspired by amazing psychology professors-in particular, Brian Little, Richard Hackman, Ellen Langer, and Tal Ben-Shahar. In reflecting on how psychology could have an impact, I realized that most people spend the majority of their time at work, yet unrewarding jobs are widespread. By studying organizational psychology and trying to make work life better, I thought I might be able to contribute something that could improve the quality of peoples' lives.

 

What inspires your research topics?

 

Many of my research projects arise from everyday experiences. For example, a recent study of hospital employee hand washing got off the ground when my wife and I were in the hospital for the birth of our first daughter. I noticed that the signs above the sinks telling doctors and nurses how to wash their hands did not track with what I knew about motivation. Healthcare professionals failing to wash their hands was not a HOW problem, it was a WHY problem-an issue of motivation. Based on my previous research, I wondered if compliance might increase if the relevant signs provided a prosocial cue and communicated the positive impact of handwashing for patients. I was lucky to partner with David Hofmann, a leading expert in health and safety, on the project and we ran an experiment. We found that signs emphasizing the consequences to patients of not washing hands were more effective at motivating the desired behavior than the signs that emphasized personal risk to the employee.

 

Given all of your research interests, why did you decide to write a book on the topics of givers, matchers, and takers?

 

Books such as Influence and Flow helped me find my career and, in fact, changed the way I looked at the world. A book written for the general public makes psychology useful to others and enables them to apply tools from psychology to their lives. I love teaching and research, and once I got tenure, I felt a responsibility to reach a broader audience and make a bigger a difference. I thought writing a book might be a step toward accomplishing that goal.

 

How did writing and publishing a book affect your research and teaching?

 

Writing the book has given me plenty of new questions to explore. During the writing process, I had to think about how to make the case for my ideas to a variety of people from different contexts. Many of the questions that occurred to me while I was immersed in writing had yet to be explored; for example, how do motivations shape the quality and quantity of our networks? Once the book came out, even more research topics emerged from reader feedback. People are really interested in figuring out how to turn a taker into a matcher or a giver. We know a lot about how to encourage people to give when in a particular role or relationship, but what causes the underlying beliefs and values to shift, so that people are more helpful even when entering a new role or relationship?

 

What advice do you have for others who are considering writing a book about their research?

 

First, determine the kinds of people you're trying to reach and what you're trying to accomplish with the book. From there, it's important to highlight what is surprising or counterintuitive about the overarching message. People often read because they are curious-they want to learn something new about a topic they thought they understood. In addition, many people read in the hopes of gathering actionable information, so another strategy is to provide practical advice in a novel way. Readers look for a book to be interesting or useful, and the best books are both.

 

What is next for you?

 

Getting back into the classroom. I miss it. I've been on a book tour, and I'm excited to welcome a new group of students to Wharton.

  

-Christine Weeks

Musings About Behavioral Economics
Helen Darling, MA
President and Chief Executive Officer, National Business Group on Health 

 

All employers, especially their HR and benefits people, know that 3 of their biggest challenges to providing affordable, quality health benefits and improving health are employees and dependents':

 

1) Poor health habits, including sedentary lifestyles;

2) Failing to take steps needed to improve their health, such as taking medications as prescribed and obtaining timely, appropriate evidence-based screenings; and 

3) Not acting on their options at Open Enrollment. 

 

Knowing these challenges explains why behavioral and social sciences have become such important resources for employers, health plans, PBMs, providers and other suppliers. We now know much more about why people don't do what they should do even when they recognize that it is very much in their own interests to do so. 

 

Thanks to behavioral economics and other behavioral sciences, instead of all of the old methods of communicating and rewarding employees, employers are beginning to develop strategies, design plans and administer benefits in ways which increase the likelihood that employees and family members will do what is needed and help make employers' investments in health benefits pay higher dividends, while supporting a higher quality of life among their employees.

 

What are examples?

Employers annually spend many months and lots of money to produce Open Enrollment materials that they hope will grab the attention of employees. I have many stories of employees wandering into my office at a Fortune 500 company with their Open Enrollment packages-which we had spent so much money and many months of editing and ERISA attorney revisions - still unopened in the plastic wrapper. Employees still complained about changes they "hadn't been warned about." They were unhappy and we were too but we struggled to get their attention when we needed it.

We now know that we were fighting the huge amounts of clutter and time constraints that employees face so we needed something that would force attention and provide a counterweight to the powerful force of inertia.
We have learned to require active choice (which is also made really easy), such as, requiring an active enrollment with a default to the cheapest plan for an individual or default to no plan.

Active enrollment is often required when the employer is making a significant enough change that attention to the new decision is critical. 
We also know we want to make the right choice the easiest choice and do whatever else might be needed when you have the employee's attention already. For example, an online enrollment system might show the employee how much money he or she would save if they only took the steps needed to earn their wellness credit. The employer might also want to set it up so that the employee or dependent gets the credit automatically at the time of Open Enrollment but will be notified that the credit will be taken away if they haven't met participation requirements within a certain period of time. Enrollment in flexible spending accounts (FSAs) is still pitifully small, especially given the tax benefits of FSAs. 

Open Enrollment might be a time to show what could be given and the tax advantages of that at the time of open enrollment and on the enrollment template, so all the employee would have to do is click on yes at the time of enrollment.
 

Other examples have to do with the failure of following the doctor's medication prescriptions. The consequences can be dire, such as strokes and heart attacks, yet adherence is still poor. Behavioral economics and other behavioral sciences help with understanding the drivers and designing the solutions to fit the very human problems that cause such poor adherence.

 

Increasingly, we will see that solutions from behavioral sciences will help reduce risk, harm and wasted expenses, as well as improve health. Bringing millions of new people into health plans through the public health insurance marketplaces will give us many opportunities to study natural experiments around the country. We should take advantage of this remarkable, historic change to learn even more.

 

-Helen Darling
New Initiatives   

Using Social Forces to Improve Medication Adherence in Stain Users With Diabetes
Principal Investigators: Kevin Volpp, MD, PhD, Judd Kessler, PhD, Peter Reese, MD, MSCE 
 

There is growing evidence of strong associations between a patient's social environment and health behavior.  Social forces are worth harnessing as a strategy to promote health behaviors because patients usually engage with their physicians and nurses during occasional health system visits, but they interact with their social networks much more frequently. Furthermore, social forces may be particularly effective at building enduring habits for healthy behavior and might be cost effective to implement.  This study proposes to complete a randomized controlled trial of 200 subjects with diabetes and evidence of poor adherence to a statin medication. Study subjects will use GlowCaps to store their statin medication. Study subjects will identify potential Medication Adherence Partners (MAPs) who can receive information about their adherence patterns at enrollment. 

 

Funded by: Merck & Co.

 

This study aims to investigate the association between a patient's social environment and health behaviors. It has been well documented in non-health domains that providing agents with information about what others are doing can be an effective motivator. Leveraging this social force might be capable of encouraging patients to build habits for healthy behavior and might be cost effective to implement. This study specifically leverages feedback and information about the performance of others to influence individual behavior. An individual can be motivated to improve his performance when he knows he will be receiving feedback about that performance. Additionally, individuals may feel compelled to compete when their performance is compared to the performance of others. This study's interventions will study the effects of feedback and information about others by varying what individuals are told about their medication adherence and how it compares to other people in the study. 

 

Funded by: Merck & Co.