This piece expands upon my prior post about digital nudging and behavioral economics. Disruption in the healthcare industry mirrors the ed-tech takeover that is well underway in public education. If you explore the webpage for Catalyst, the innovation PR outlet for the New England Journal of Medicine (remember, social impact policy makers and many investors are based in Boston), you’ll notice the language being used to direct health care providers towards big-data, tech-centered solutions is eerily similar to the language being used on educators and school administrators.
The FCC’s “Connecting America: The National Broadband Plan” of 2010 outlined seven “national purposes” for broadband expansion. Healthcare and education were the first two topics covered in that report. Both chapters focus on “unlocking the value of data.” Who will the big winners be as we further digitize our lives? My assessment is the telecommunications industry and national security/police state will come out on top. Locally, Comcast and Verizon are key players with interests in both sectors.
Education and healthcare fall under the purview of Lamar Alexander’s Senate HELP (health, education, labor and pensions) Committee, so the similarities in tactics shouldn’t come as a surprise. In researching the $100 million federal Social Impact Partnerships Pay for Results Act (SIPPRA) launch I attended in Washington, DC last month, I noticed one of the Republican Senators who presented, Todd Young of Indiana, had attended the Booth School of Business MBA program at the University of Chicago. Recent Nobel Prize winner in behavioral economics Richard Thaler teaches there, and I was curious to see if Thaler’s thinking had influenced Young. Interactive version of Young’s map here.
I located C-SPAN coverage of a Senate hearing on healthy lifestyle choices, which Young participated in on October 19, 2017 (transcript follows). Lamar Alexander and ranking member Patty Murray, who inserted Pay for Success provisions into ESSA, chaired that hearing. Behavioral economics was discussed extensively. Young’s remarks start at timestamp 34:00.
The topic of the hearing was reducing healthcare expenditures on chronic illness, which they claimed would amount of hundreds of billions of dollars in “savings.” Given the amount of money on the table, it seems clear this sector is ripe for outsourced, outcomes-based contracts that will deploy emerging technologies like health care wearables. Six measures of good health were identified during testimony: blood pressure, cholesterol level, body mass index, blood sugar, smoking status and either the ability to meet the physical requirements of your job (or on this one the Cleveland Clinic person said unmanaged stress.)
The claim was that if an insured person met four of the six measures, saw a doctor regularly, and had their vaccinations up to date they would avoid chronic illness 80% of the time. Of course the conversation was entirely structured around individual “choice” rather than economic and racial systems that make it difficult for people to maintain a healthy lifestyle.
This neoliberal approach presumes people have free time for regular exercise, not considering they may be cobbling together several gigs to make ends meet. It presumes the availability of healthy food choices, when many black and brown communities are food deserts with limited access to fresh produce. It presumes the stress in people’s lives can be managed through medicalized interventions and does not address root causes of stress in communities steeped in trauma. It presumes ready access to a primary care physician in one’s community.
It is a gross simplification to push responsibility for chronic health conditions solely onto the individual, giving a free pass to social systems designed to harm large subsets of our communities. By adopting a data-driven approach to health outcomes, as would seem to be the case with the above six measures (check a box health), the federal government and health care systems appear to be setting health care consumers up to become vehicles for data generation in ways that are very much like what is happening to public education students forced to access instruction via digital devices. Imagine standards-based grading, but with health measures.
The people who provided testimony at the October 19 hearing included Steve Byrd, former CEO of Safeway, now at Byrd Health; Michael Roizen of the Cleveland Clinic; David Asch Director of the Wharton School’s Center for Health Care Innovation; and Jennifer Mathis of the Baselon Center for Mental Health Law and representing the Consortium for Citizens with Disabilities. Mathis was the only one who testified strongly on behalf of the rights of the insured to withhold personal information and was very concerned about the discriminatory nature of incentivized medical insurance programs, particular with regards to people with disabilities.
In his testimony, David Asch, director of the Center for Healthcare Innovation based in the University of Pennsylvania’s Wharton Business School, described effective designs for health incentive programs, noting that concerns about losing money were more effective from the insurer’s point of view that interest in receiving financial rewards. For that reason Asch said taking away money from someone should be considered before offering a reward. Asch also noted that effective programs included emotional engagement, frequent rewards (tweaked to people’s psychological foibles to they didn’t have to be too large), contests and social norming, including the use of public leader boards.
The date of the hearing is interesting, because right around the same time, public employees (including the teachers) of West Virginia were facing dramatic changes to their insurance plans. These changes included compulsory participation in Go365 an app-based health incentive program that imposed completion of intrusive surveys, wearing a fit bit (if you didn’t there was a $25 fee imposed each month), and meeting a certain step count per day. I include a transcription of testimony from one of these teachers, Brandon Wolford, given at this spring’s Labor Notes conference at the end of this post.
The incorporation of mHealth (mobile health) technologies is a key element of the healthcare disruption process. Increasingly, wearable technologies will transmit real-time data, surveilling the bodies of the insured. mHealth solutions are being built into healthcare protocols, so private investors will be able to track which treatments offer “high-value care.” The use of wearables and health apps also permits corporate health systems to insert digital “nudges” derived from calculated behavioral economic design, into the care provided, and monitor which patients comply, and which do not.
At the moment, the tech industry is working intently to integrate Blockchain technology and Internet of Things sensors like fit bits and health apps on smartphones. Many anticipate Blockchain will become a tool for securing IoT transmissions, enabling the creation of comprehensive and supposedly immutable health data logs, which could be key to mHealth expansion. Last summer the Medical Society of Delaware, a state that touts itself as a Blockchain innovator, announced a partnership with Symbiont, to develop healthcare records on Blockchain. Symbiont’s website claims it is the “market-leading smart contracts platform for institutional applications of Blockchain technology.” The company’s initial seed round of funding took place in 2014 with a second round raising an additional $15 million in May 2017 according to their Crunchbase profile.
The July/August 2018 issue of the Pennsylvania Gazette, the alumni magazine for the University of Pennsylvania, features Blockchain as its cover story, “Blockchain Fever.” The extensive article outlines use cases being considered for Blockchain deployment, including plans by a recent Wharton graduate to develop an application that would certify interactions between healthcare agencies and Medicare/Medicaid recipients for reimbursement. The University of Pennsylvania Health System is deep into innovative technologies. David Asch, director of Penn’s Center for Health Innovation, testified at the October 2017 hearing. The Penn Medicine integrated health system was created in 2001 by former UPenn president Judith Rodin in collaboration with Comcast Executive David Cohen. Rodin went on to head the Rockefeller Foundation, and in the years that followed the foundation spearheaded the creation of the Global Impact Investment Network. GIIN fostered growth of the social impact investing sector, at the same time healthcare began to transition away from a pay-for-service reimbursement towards a value-based model predicated on outcomes met.
Below is a relationship map showing the University of Pennsylvania’s involvement in “innovative” healthcare delivery, which I believe stems from Rodin and Cohen’s connections to Comcast. It is important to note that the Center for Health Innovations claims to have the first “nudge unit” embedded within a health system. Asch is an employee of Wharton, and Wharton is leading initiatives in people analytics, behavior change via tech, and Blockchain technologies. Interactive version of the map here.
New types of employer-based health insurance systems have started to emerge over the past six months. Based on this New York Times article, it seems employees of Amazon, JPMorgan and Berkshire Hathaway will have a front row seat as these technological manipulations unfold. Last fall Sidewalk Labs, the “smart cities” initiative of Alphabet (parent company of Google), announced an expansion into managed healthcare. City Block (read Blockchain) will tackle “urban health” and populations with “complex health needs.”
Reading between the lines, it appears Alphabet aims to use poor black and brown communities that have experienced generations of trauma as profit centers. Structural racism has created a massive build up of negative health outcomes over generations. Now, with innovative financial and technological infrastructures being rapidly put into place, these communities are highly vulnerable. Ever wonder why ACES (Adverse Childhood Experiences) has scores? I expect those numbers are about to be fed into predictive profiles guiding social investment impact metrics.
How convenient that the “smart city” solutions Sidewalk Labs is likely to promote will come with IoT sensors embedded in public spaces. How convenient that healthcare accelerators are developing emerging technologies to track patient compliance down to IoT enabled pill bottle caps; sensors that allow corporate and government interests to track a person’s actions with precision, while assessing their health metrics in excruciatingly profitable detail. Technology platforms are central to City Block’s healthcare program. Many services will take place online, including behavioral health interventions, with the aim of consolidating as much data as possible to build predictive profiles of individuals and facilitate the evaluation of impact investing deals.
Interesting aside, I have two friends who had emergency room visits at Jefferson Hospital this summer and were “seen” by doctors on a screen with an in-room facilitator wielding a camera for examination purposes. This is in a major East Coast city served by numerous research hospitals. Philadelphia is not Alaska. Where is that data going? Where were those doctors anyway?
As these surveillance technologies move full steam ahead, it would be wise for progressive voices invested in the “healthcare for all” conversation to begin considering strategies to address the serious ethical concerns surrounding wearable technologies, tele-health / tele-therapy, and value-based patient healthcare contracting. If guardrails are not put in place that guarantee humane delivery of care without data profiling, the medical establishment may very well be hijacked by global fin-tech interests.
As someone who values the essence of the platform put forward by Alexandria Ocasio Cortez, I worry she and her supporters do not understand several key elements of her platform have already been identified as growth sectors for Pay for Success. If public education, healthcare, housing and justice reform are channeled by global financial interests into outsourced-based contracts tied to Internet of Things tracking, we will end up in an even worse place than we are now. So, if you care about progressive causes, please, please get up to speed on these technological developments. You can be sure ALEC already has, and remember that Alibaba (Sesame Credit) joined in December. It’s not too much of a stretch to imagine patient rating systems regulating healthcare access down the road if we’re not careful.
Senator Todd Young was the first person to respond to witness testimony during the hearing, and his line of questioning revealed he is a strong advocate of Thaler’s “nudge” strategies. The “nudge” is a key feature of “what works” “Moneyball” government that deploys austerity to push outsourcing and data-driven “solutions” that embrace digital platforms that will gather the data required prove “impact” and reap financial returns. See this related post from fellow researcher Carolyn Leith “A Close Reading of Moneyball for Government and Why You Should Be Worried.”
Young asked David Asch of Wharton’s Center for Innovative Health, what employers could learn from behavioral economists? He also posed several specific suggestions that would scale such programs within the federal government namely: embedding units charged with experimenting with behavioral economics into federal government programs; developing a clearinghouse of best practices; and bringing in behavioral scientists into the Congressional Budget Office.
Asch, a doctor employed by the Wharton Business School, runs UPenn’s Center for Health Care Innovation created in 2011 to test and implement “new strategies to reimagine health care delivery for dramatically better VALUE and patient OUTCOMES” (emphasis added). The 28,000-foot facility houses simulation learning labs and an accelerator where research on use of “smart” hospital systems, social media, and emerging technologies in healthcare is conducted. The accelerator aims to rapidly prototype and scale “high impact solutions,” read Pay for Success.
Besides the Acceleration Lab, the Center also contains the Nudge Unit, which according to their website is the world’s first behavioral design team embedded within a health system. The goal of the unit is to “steer medical decision making towards HIGHER VALUE and improved patient outcomes (emphasis added).” Sample healthcare nudges include embedded prompts in digital platforms (for screenings), changing default settings (to generic prescriptions), framing information provided to clinicians (not sure what this means), and framing financial incentives as a loss.
This is longer than intended and hopefully provides some food for thought. This life datifying impact investing machine we are up against isn’t just coming for public education; it’s coming for ALL human service. We need to begin to understand the depth and breadth of this threat. I’m still mulling over a lot of this myself, and my knowledge base in healthcare is much shallower than my expertise in education. I’d love to hear what folks think in the comments or if you know of others writing on blockchain and IoT in medicine with a critical lens send me some links. Below are transcripts from West Virginia teacher Brandon Wolford about Go365 followed by the Senator Young / David Asch hearing exchange.
Brandon Wolford, West Virginia Teacher: When I first began teaching in 2012 the insurance, in my opinion, was excellent, because I had worked for one year in Kentucky and I had known that the premiums were, although they were being paid five to seven thousand more than we were, they still had to pay much more for their insurance. So it balanced out. However, after the first year or two I was there, that was when they started coming after us with the tax on our insurance. First of all the premiums, we started to see slight increases for one, and another was they started to enforce this “Healthy Tomorrows” policy.
So, the next thing you know, we get a paper in the mail that says, you know, you have go to the doctor by such and such a date. It must be reported. Your blood glucose levels must be at a certain amount. Your waist size must be a certain amount, and if it is not, if you don’t meet all of these stipulations then you get a $500 penalty on your out-of-pocket deductible. So, luckily for me, I eat everything I want, but I was healthy. My wife on the other hand, who eats much better than I do, salads at every meal, has high cholesterol, so she gets that $500 slapped on her just like that.
Okay so, that was how they started out. In the mean time, we have been filling these out for a year or two, and they keep saying you know you have to go back each year and be checked. And then comes the event that awoke the sleeping giants. The PEIA Board, which is the Public Employee Insurance Agency that represents the state of West Virginia, they, um it’s just a board of four to five individuals that are appointed by the governor, they are not elected. They have no one they answer to; they just come up with these things on their own.
So they come to us and they say we’re raising your premiums. This was somewhere between November and December of last year. We’re raising your premiums. You’re going to need to be enrolled in a program called Go365, which means that you have to wear a fit bit, as well record all of your steps. You have to check in with them, and it included private questions like how much sexual activity do you perform, and is it vigorous? All of these things that they wanted us to report on our personal lives, and that was all included. In addition to that we had to report all of those things, and if we refused to wear that fit bit and record all of our steps, or if we didn’t make our steps, we were going to be charged an additional $25 per month.
So, when everyone sees this along with the increased premiums, then they’ve also introduced a couple more bills to go along with that, because the PEIA Board, they have the final say. Whatever they do, it’s not voted upon by the legislature. It’s basically just law, once they decide it. But in the meantime our legislature was presenting these bills. We were currently on a plan of sixty, uh excuse me, eighty/twenty we were paying out of pocket. Well, they had proposed a bill that would double that and make us pay sixty/forty.
So, they presented that along with charter school bills and a couple of other things that were just direct attacks on us. We had been going by a process of seniority for several years; and they also introduced a bill to eliminate seniority to where it was up to the superintendent whether or not you got to stay in your position. It was up to the principal and regardless if you were there thirty years or you were there for your first or your second year…they were trying to tell us you know, it’s just up to your principal to decide. The superintendent decides. They don’t want you to go, you’ve been there for thirty years and you have a masters degree plus forty-five hours, you’re gone. It’s up to them. Your seniority no longer matters. So those things combined with the insurance is actually what got things going in our state.
Excerpted Testimony Healthy Lifestyle Choices, Senate HELP Committee 10/19/17
Lamar Alexander: We’ll now have a round of five-minute questions. We’ll start with Senator Young.
Senator Todd Young: Thank you Chairman. I’m very excited about this hearing, because I know a number of our witnesses have discussed in their testimonies behavioral economics and behavioral decision-making. I think it’s really important that we as policy makers incorporate how people really behave. Not according to an economist per se, or according to other policy experts, but based on observed behaviors. Often times we behave in ways that we don’t intend to. It leads us to results that we don’t want to end up in.
So, Mr. Asch, I’ll start with you, with your expertise in this area. You’ve indicated behavioral economics is being used to help doctors and patients make better decisions and you see opportunities for employers to help Americans change their behaviors in ways they want from tobacco mitigation to losing weight to managing blood pressure and you indicate those changes are much less likely to come from typical premium-based financial incentives and much more likely to come from approaches that reflect the underlying psychology of how people make decisions, encouraged by frequent rewards, emotional engagement, contests, and social acceptance and so forth. And you said in your verbal testimony you haven’t seen much of this new knowledge applied effectively by employers, but there’s no reason why it cannot be. So, my question for you sir is what might employers learn from behavioral economists. Just in summary fashion.
David Asch, Wharton Center for Health Care Innovation: Sure. Thank you senator. I think I’ll start by saying there is a misunderstanding often about behavioral economics and health. Many people believe that if you use financial incentives to change behavior you’re engaged in behavioral economics, and I would say no, that’s just economics. It becomes behavioral economic when you use an understanding of our little psychological foibles and pitfalls to sort of supercharge the incentives and make them more potent so that you don’t have to use incentives that are so large.
So I think that there are a variety of approaches that come from behavioral economics that can be applied in employment setting and elsewhere. I mentioned one, which is capitalizing on the notion that losses looms larger than gains, might be a new way to structure financial incentives in the employment setting in ways that might make it more potent and more palatable and easier for all employees to participate in programs to advance their health. The delivery of incentives more frequently for example. Or using contests or using certain kinds of social norming where it’s acceptable to show people on leader boards in contests and get people engaged in fun for their health. All of these are possibilities.
Senator Todd Young: Thank you very much. You really need to study these different phenomena individually. I think to have a sense of the growing body of work that is behavioral economics. Right, so we need the increased awareness, and I guess the education of many employers about some of these tics we have. That seems to be part of the answer. In fact, Richard Thaler who just won the Nobel Prize for his ground-breaking work in this area indicated that we as policy makers ought to have on a regular basis not just lawyers and economists at the tables where we’re drafting legislation, but ought to have a behavioral scientist as well.
And the UK, they have the Behavioral Insights Team. The United States, our previous administration, had a similar sort of team that did a number of experiments to figure out how policies would actually impact an individual’s health and wellness and a number of other things. Some of the ideas that I think we might incorporate into the government context, and tell me if any of these sort pop for you; if you think they make sense?
We need to continue to have a unit or units embedded within government that do a lot of these experiments. We need to have a clearinghouse of best practices that other employers included might draw on. This doesn’t have to be governmental, but it could certainly be. We on Capitol Hill might actually consider aside from having a Congressional budget office than an official budget office, we might have an entity or at least some presence within the CBO or individuals that understand how people would actually respond to given proposals. Do any or all of those make sense to you?
David Asch: Thank you for your remarks. Yes, I think they all make sense. And one of the lessons that I guess I have repeatedly learned is that seeming subtle differences in design can make a huge difference in how effective a program can be and how it is perceived and that will ultimately care about the impact of these programs. So, I am very much in favor in the use of these programs, but in addition, greater study of these programs, because I think we need an investment in the science that will help all of us in delivering these activities, not just in healthcare, but in other parts of society.
Senator Young: That makes sense. I am out of time. Thank you.