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The Targeted Problem
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Chronic disease costs represent approximately 75% of the total health care expenditures in the U.S.1 The constellation of diseases around Type II diabetes, a self-inflicted chronic disease, are the most troubling to health policy experts.2 More than half of all chronic disease costs are instigated by lifestyle choices and unhealthy – but correctable – behaviors; most notably, poor nutrition, high fat diets, unbridled portion control, tobacco use, exposure to stress, alcohol abuse, insufficient sleep, and sedentary lifestyles.3 66% of adult Americans fail to engage in regular physical activity4 and two-thirds of us are overweight or obese.5 Health insurance sponsors have not been exempted from the burden of chronic diseases that have been self-inflicted through poor lifestyle choices. We predict that an actuarial assessment will elucidate that over 1/3 of the health care spend by these organizations is correlated to behavior specifically associated with unhealthy living.
As experts are learning, lifestyle choices are not an access-to-care or health care economics issue. Rather, the choices Americans seem to consistently embrace fall under a litany of behavioral economics precepts, including inability to defer gratification, overweighting of short term versus long term gains, loss aversion, and sensory overload, to name a few. Furthermore, spending an average two hours a year in obtaining advice from a physician is dwarfed by the other 300+ days of the year when adults are not "patients," and must rely on their own self-management and self-control.
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The Targeted Solution
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In a nutshell, Healthrageous provides automated coaching over the Web and through an iPhone, Android and Blackberry compatible mobile app, coupled with biometric devices and sensors to assist people in changing health-compromising behaviors (e.g., eating too much, getting sufficiently active each day, smoking, lack of adherence to prescribed medications).
The key to altering the cost curve associated with poor lifestyle choices is to offer a multi-pronged, highly individualized solution to each targeted person. Abiding by the maxim, "some of the things work for some of the people some of the time," Healthrageous has deftly deployed a series of tools that when combined across an entire population is achieving remarkable success in enabling and ultimately empowering people to change behaviors.
Social Networks. People are often as influenced by friends and associates, as they are by their physicians.6 By allowing interaction between people striving to deal with the same challenge (e.g., diet, exercise, smoking cessation), Healthrageous has facilitated sustained engagement at a very modest cost. Social networks are scalable, influential, and easily accessible in the palm of one's hand.
You Can't Manage What You Don't Measure. Many adults fall back on a tired excuse of not knowing how many calories are in a Big Mac or Hot Fudge Sundae. By making the tracking of data friction free and fun, Healthrageous has increased self-awareness to all sorts of measurable metrics – steps, hours slept, stress levels, # of fast food visits/week, # of 8 oz. glasses of water consumed, etc. Data can be captured through integration of wireless biometric devices or it can be self-reported.
Make it Fun. Why do people love Farmville or Angry Birds? They become addictive diversions. Easy to play. Not a time hog. Thrill of victory; agony of defeat. Many adults avoid making physician appointments because they don't want to hear bad news or counsel that will require change. By adopting gaming techniques and principles into the Healthrageous platform, we have succeeded in making health fun.
Health Must Be Convenient. Open heart surgery is hardly convenient. But many of the preventive steps leading to it can occur effortlessly, without a second thought. Placing health care in the palm of one's hand, however, increases the likelihood that health starts to wrestle for one's attention with other "front of mind" concerns (e.g., the kids, the job, family finances, parents' health, the pets, cost of education, etc.). As has become patently clear at many of today's health plans, when health is relegated to a patient portal buried through multiple logins and password refreshes, it will get little or no attention.
Timely Data Access. By waiting an inordinate time for test or lab results, people lose the sense of urgency with which they initially addressed a health issue. Healthrageous provides data visualization on the smartphone for easy-to-discern conclusions about trending. Further, goal achievement cannot occur if the status against goal is only communicated after the day has ended. Also, reminders and alerts can be programmed to arrive in real time, when they are needed and actionable.7
Interactive and Dynamic Data. Timely data is a laudable goal. But what of the Health Risk Appraisal? Many employers pay their employees lots of money to complete HRAs. Once a year, the effort is renewed. Healthrageous has abandoned HRAs for several reasons: 1) they cost too much; 2) they are static; 3) they are so tediously long to complete, that fraudulent data creeps into the answers undermining validity; and 4) long turnaround times make them less timely and actionable. By asking a brief set of questions (i.e., 12), in a convenient setting, and then following up with a question a week to amplify some issues, Healthrageous has infused dynamic personalization into its HRA alternative. Voila: Greater responsiveness. And, more importantly, consumers start to see that Healthrageous is noting information already provided.
Goal Creation. Many a dieter has fallen victim to an overly-ambitious diet goal. "I'm going to lose 50 pounds in the next two months." Or, "I'll fast and lose 10 pounds before the weekend." Goal achievement works when the targeted pursuit is achievable and measurable.8 It helps to start modestly and build to more ambitious long-term objectives. Healthrageous deploys a goal-setting methodology that starts where each person is...not where they want to be. Gradual increases in daily goals over weeks and months ensure that success can occur. Goals are individualized around each participant. A common currency, KUDOs, allows for competition between different goals and different pursuits.
Recognition and Rewards. Many people experience a sense of pride when reaching a milestone.9,10 The Healthrageous system of badging and congratulatory emails is designed to exploit opportunities for intrinsic motivation. Healthrageous customers have seen logic in augmenting these intrinsic rewards with lotteries, gift cards, premium reductions, HSA deposits, and paid days off to amp up the results achieved in the targeted population. Whether with praise or something more tangible, Healthrageous believes that carrots are more successful than sticks in motivating sustained engagement and change.
Multi-Pronged Solutions. One size does not fit all. In the disease management world that enveloped health plans for more than a decade, two notable errors seemed to persist across most programs. 1) People were not encouraged to pick what they wanted to work on; rather they were incentivized to do something to help their employer. 2) If they opted for diabetes, for instance, they had but one way to improve their health – measure glucose routinely. By asking people what they want to work on and by offering diabetics many ways to improve their Hemoglobin A1c scores (more sleep, more exercise, added sugar in diet, improved blood pressure management, test glucose routinely, and adhere to prescribed meds), more people will choose to join and activate. Not only can diabetics in the same health plan choose to join different diabetic solution clusters, but Healthrageous also offers programs for more than just diabetics.
Inspiration. If we won't do something for our employer and we are not moved to try and change, in spite of financial rewards that await our achievements, then what will invoke meaningful change? What inspires you? If I want to live to see my grandchild graduate from college, then I may need to change my ice cream obsession every night. Healthrageous places each participant's inspiration front and center on his/her home page. Or...right there on the smartphone. It takes up real estate because it is IMPORTANT. Reminding us why we get out of bed every morning can be a good thing.
Packaging Not Education. Most Americans who have succumbed to a consistently unhealthy lifestyle choice are not suffering from a health literacy challenge. Teen smokers may think that it looks cool to smoke and therein lies the rub. Madison Avenue techniques aimed at vulnerable consumers will inevitably overwhelm the doctor's carefully meted out advice at the point of sale. That's why checkout aisles are bursting with confection choices. Healthrageous has adopted many of the design principles that sell popular products.11,12
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Early Results
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Though the company is less than a year old and the general product release occurred in July 2011, preliminary data is encouraging. Prior to the creation of Healthrageous, the company was conceived and incubated at the Center for Connected Health within Partners Healthcare. It was there that the magic of self-management was proven in a 2009 Randomized Clinical Trial (RCT) for hypertension with 404 EMC employees in Eastern Massachusetts. The program was called SmartBeat. The volunteers with hypertension were randomly divided into two equal groups. Those in the intervention group were told that to maintain participation, they had to take their blood pressure 3 times a week with a connected blood pressure cuff and then log into the SmartBeat web site at least once each week to receive tips and pointers on how to improve their hypertensive lifestyles. Each web site review also brought the employee up close and personal with his/her actual BP scores for the last week, month, etc. They were receiving a biofeedback loop of their own specific data with augmenting information on how to improve it.
Those in the control group also had opportunities to improve their blood pressure, including visits to their doctors for medication consults. When the results were analyzed, the SmartBeat team was amazed by the amount of stickiness, i.e., treatment adherence, in the intervention group; only 3% out of 197 employees dropped out of the program over the 6-month study. Equally impressive were the clinical results, shown here in Figure 1. Employees in the intervention group were statistically significantly more likely to have lowered their blood pressure, gotten on a new blood pressure medication, and reported better communication with their doctor as a result of the study, compared to those in the control group. The team that developed SmartBeat concluded that when health data is personal, timely, and convenient to access, it becomes studied and actionable.
Armed with impressive results from the RCT, the Center for Connected Health decided to commercialize its findings into a health care service, Healthrageous. Results obtained from initial clients suggest that the EMC trial was not an aberration.
Different employee populations in different parts of the country are obtaining similar results. The Healthrageous program is equally beneficial for those attempting to lose weight and/or increase their physical activity as it is for customers focused on hypertension improvement.
Among individuals, for whom data was captured between September 2010 and September 2011, 30% of the hypertensive patients are achieving a meaningfully clinical improvement in their hypertension. And for those loaded up with an accelerometer to capture their step counts and report them to their smartphones, 14% had increased step counts by at least a mile/day during engagement with the program.
The statistics that were equally compelling occurred in sustained engagement. Most employers and health plans have become quite pessimistic about sustained engagement. The vendors supplying disease management solutions not only failed to impress their customers, but some were also accused of stretching the truth or redefining engagement to mean "receipt of direct mail," or "opened an informational email." Healthrageous defines sustained engagement as participation (as proven by wireless data feeds or proactive logins to the platform) of at least 12 weeks.
Across its book of business, Healthrageous is achieving:
- 96% proactive engagement (upload wireless device data or log into platform) among those who sign up for program
- 65% remained engaged for at least 12 weeks
Of the book of business, approximately one-half of the participants were focused on managing hypertension. Of those participating in hypertension management 62% maintained engagement with blood pressure monitoring for more than 12 weeks and 30% achieved clinical significant improvement in diastolic and systolic blood pressure.
In the Physical Activity programs involving the other half of the book of business participants, 65% of participants were actively engaged beyond 12 weeks and 14% achieved a significant increase in daily physical activity.
Results achieved by Healthrageous have appeared in other settings. Kaiser armed members with wireless blood pressure devices. The readings were observed and acted on by pharmacists. In this wireless hypertension study, the likelihood of blood pressure control was increased by 50%.13
Healthrageous is in the initial phase of implementing Dee Edington Ph.D.'s "Natural Flow of Risk Transitions"14 methodology to project the financial savings that can be achieved by engaging a higher number of individuals within a population in reducing health risk factors. Through his analysis of claims for two million commercially insured lives, Dr. Edington has quantified the relationship between risk levels and corporate cost measures15 and he has identified excess healthcare costs per health risk behavior in the amount of $1,500 to $3,500. By impacting hypertension, Healthrageous could eliminate one large and costly risk factor. We are eager to partner with organizations with expertise in claims analysis in order to validate the projected financial savings methodology against claims experience.
A randomized controlled trial in the United States found diabetic patients using an mHealth solution reduced their A1C levels by nearly two points. (Every one point reduction in A1C has been shown to reduce diabetes complications by 37 percent).16
A connected health diabetes program at Howard University, Washington, D.C. found that the intervention group was 4.6 times more likely to have a hemoglobin AIC level drop below the target line than the control group.17
Sustained engagement is what employers are searching for. Today, Corporate America loses $31 billion each year on theft, lack of productivity, absenteeism, and defects/errors.18 To bring energy back into the workplace with wellness and improved health will be an HR Manager's prime goal.
Further refinement at Healthrageous is called for. The platform from which the early results were extracted has now been significantly improved and early data suggests that future results will be greatly improved, even though Healthrageous is already industry leading by several key metrics. But it is safe to say that Healthrageous has a good head start on being the early mover in self-management lifestyle behavioral change.
More devices will emerge in the market. Better apps will appear. Greater personalization will evolve. The possibility that these refinements will bring accountability for health back to the consumer, the individual making the lifestyle choices, is promising. That's the movement that Healthrageous is banking on; that's the Healthrageous Effect.
Please visit our web site for more information and we would be delighted to meet with you to explore this solution. We are finding that as health plans work with us to delve into the cost associated with the behaviors we address, care improvement and financial opportunity become readily illuminated.
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