Pioneering Ideas

Eight Innovative Ideas to Influence Health Behavior

The majority of my work in the Department of Research and Evaluation at the Robert Wood Johnson Foundation has been predicated on the long-held assumption that if you show people convincingly that doing one thing will create the outcome they desire, you can inspire behavior change. The problem is that when it comes to health, we consistently observe individuals acting in ways guaranteed to produce poor outcomes.

The observation of seemingly “irrational” behavior by economists, psychologists and others led to the development of the field of behavioral economics, which has, in recent years, produced insight to explain some of the perplexing health behaviors we observe in a way that the classical economic theories I learned in graduate school cannot. The Robert Wood Johnson Foundation believes these emerging insights have breakthrough potential to help people make better choices for their health. That’s why I’m excited to announce that the Pioneer Portfolio and Donaghue Foundation are now supporting a group of innovative researchers who are testing simple interventions that may have widespread impact on complex problems.

Last fall we asked behavioral economists, choice theorists, and others studying habit formation or physiological mechanisms to submit new ideas to help people make the “right” decisions for their health. After narrowing the field for our Applying Behavioral Economics to Perplexing Health and Health Care Challenges solicitation from an initial 330 responses to 25 finalists, we’ve selected the following eight grantees:

• Anne Thorndike, Massachusetts General Hospital, Feedback, incentives and point-of-purchase interventions to engage employees in healthy eating behaviors
• Elizabeth Merrick and Dominic Hodgkin, Brandeis University, Using novel patient financial incentives to improve uptake of routine mammography
• Ellen Magenheim and David Huffman, Swarthmore College, Fighting viruses with viral marketing? Using online social endorsements to enhance incentives to sign up for flu vaccinations
• Gretchen Chapman and Elliot Coups, Rutgers University and University of Medicine and Dentistry New Jersey, Walking with prospect theory
• Judd Kessler, Eric Zwick and Dmitry Taubinsky, University of Pennsylvania and Harvard University, Using behavioral economics to promote medication adherence and habit formation
• Justin Sydnor, Heather Royer and Mark Stehr, University of Wisconsin, University of California and Drexel University, Improving the structure of financial incentives for exercise: insights from behavioral economics
• Karen Glanz and Jason Karlawish, University of Pennsylvania, Social goals and individual incentives to promote walking in older adults
• Paul Resnick and Caroline Richardson, University of Michigan, Impacts of public announcements of goals and outcomes on goal completion

Typically, the phrase “pioneering ideas” brings to mind cutting edge technology, and the most advanced science. What’s pioneering about these new grantees is that they recognize how small, low-cost ideas that are easy to implement can create a big change.

We are looking forward to working with the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute and seeing how these ideas pan out over the next 18 months. We embrace the risk that some of these great ideas will fail to produce lasting change. Stay tuned, because next year we’ll convene each research team to share their findings—expected and unexpected—and to look for ways to spread the best ideas to those who most need a breakthrough solution.

The Potential to Solve Perplexing Health Problems

In October, RWJF’s Pioneer portfolio laid down a challenge. Recognizing that good health behaviors often require behavior change, but that making those changes is usually easier said than done, we asked the pioneering world of behavioral economics to come up with solutions—innovative ideas to help people make the “right” decisions for their health.

The results were unbelievable. We’re excited to announce that Robert Wood Johnson Foundation’s Pioneer portfolio received more than 330 responses—a plethora of ideas drawing on behavioral economics to address tough health problems—in reply to our recent call for proposals.

We received applications from a variety of institutions, including universities, business schools, schools of public health, medical schools, clinics, non-profits, and research organizations. Our hope was to discover new interventions and insights that have potential to transform health and health care. In particular, we stated an interest in experiments that test innovative solutions to the challenges of obesity and consumer engagement. More than 50 percent of the applications we received focus on problems involving obesity. Nearly one-third involve consumer engagement. We are eager to dig into these as well as the investigator-initiated topics and invite those with the most pioneering ideas to submit a full proposal later this month.

RWJF’s Pioneer portfolio supports unconventional approaches to difficult problems—visionary solutions that have the potential to change the way we think about health and health care. We are the only RWJF team that accepts unsolicited proposals; however, when we target an area that we think deserves more attention, we are often humbled and excited by the caliber of the results.  I extend my warmest thanks to those scientists, economists, physicians and big thinkers who submitted your pioneering ideas as an answer to this call and to all those in our network who helped spread the word.

Decisions, Decisions…Behavioral Economics and Behavioral Change

To improve people’s health, we ask them to change their behavior. Quit Smoking. Eat right. Lose Weight. Take a walk. Get your blood pressure checked. See a doctor. But, as many have noted, making a commitment to do the “right” thing is often easier than following through on that commitment.  In fact, many of the nation’s health epidemics are linked to people doing the “wrong” thing despite their best intentions.  Assuming that people want to feel good and live healthy, productive lives, how can we explain actions that unequivocally threaten that outcome?  As a classically trained economist, I am sorry to say: Classical economics can’t give us an answer to that question.  Wearing the hat of program officer with the Robert Wood Johnson Foundation’s Pioneer Portfolio, I’m charged with searching, often in unexpected places, for pioneering ideas that have the potential to accelerate change and radically improve our health and the health care we receive. This quest has led the Pioneer Portfolio to the doorstep of behavioral economics.

Unlike classical economics, which assumes people act rationally and make choices in their best interest, behavioral economics does not assume that people behave in ways that maximize their income or long term happiness and wellbeing.   Rather, behavioral economist study how various factors such as environment and psychology lead people to sub-optimal outcomes. Pioneer is seeking ideas from this field because we understand that, in addition to the social determinants of health that we cannot individually control, we are constantly making conscious and unconscious decisions that relate directly and indirectly to our health. We choose whether or not to take our medication. We select the foods we eat. We decide whether to take the stairs or go to the gym.  

When we interact with the health care system, our health care providers make decisions that impact our understanding of our health condition and our treatment protocol. Doctors decide whether to use positive reinforcement or fear tactics to motivate a patient, encourage her to stop smoking, or ask her to get a test. Nurses choose whether to speak up during rounds and how to impart knowledge to a patient when he is discharged from the hospital.  Insurers seek to influence our decisions with financial incentives related to choice of physician, care facility and frequency of interaction with the health system. The frequency of these decisions is important because when we – or our providers – make poor decisions, our chances for a long, healthy life are hurt.

The emerging field of behavioral economics is working to discover how people make decisions that can affect their health behaviors and health care, and how we can learn to guide people toward decisions that are in their best interest, even if they are hard, inconvenient or easy to forget. With this knowledge, policymakers and others can design environments, campaigns, messages and tools that make it easier for people to choose what is best for themselves, their families and their communities.

That’s why the Robert Wood Johnson Foundation’s Pioneer Portfolio has issued a call for proposals to identify promising experiments that apply the principles and methods of behavioral economics and choice theory to perplexing health and health care problems. By tapping into the behavioral economics community, we hope to uncover pioneering interventions and policies that will transform the way patients and providers make decisions that affect health for ourselves and our communities.

It is our hope that behavioral economists can help us learn how people think about their health and the decisions they make. Some research we fund will fail, but that’s okay–there will be critical lessons learned from these experiments. The successes and the failures will help to educate our work to transform health and health care for the better.

We’re seeking innovative ideas that apply the field’s principles and theories to perplexing health problems. We are particularly interested in supporting either experiments or secondary data analyses that test innovative solutions to the challenges of obesity and consumer engagement, but any problem can be addressed.

Do you have an idea of how behavioral economics can help change health and health care? Can you think of a health problem that can be transformed by learning more about how patients and providers make decisions about the care they give and receive? If you don’t plan to submit a proposal, leave a comment– I’d love to hear your pioneering ideas.

Register here for an informational web conference on October 19 at 11:00 a.m. Eastern. The Robert Wood Johnson Foundation will discuss and answer programmatic questions about Pioneer's new funding initiative, Applying Behavioral Economics to Perplexing Problems.

Discovering the Pioneering Genome: A Few Final Thoughts From TED

My framework and perspective on measuring “pioneer-ness” has been radically altered by what I have seen and heard at TED.  What began as a traditional academic exercise of collecting data to examine a hypothesis and testing fit of predictions has evolved into a task of discovery – a quest to discover the “pioneering” genome.

Jim Hornthal gave a memorable talk in TED university (a series of short talks held in a smaller theater than the official “TED TALKS”) about the importance of pattern recognition, a quality another speaker said that only humans, not computers, possess.   

Pattern recognition can help us discover useful information we didn’t know we were looking for. Jim talked about several ways humans seek assistance when making a decision. 

• Rely on experts
• Rely on friends
• Check with crowds
• Use algorithms to understand complex data, such as what’s currently being done in genomics

We’ve used the first two to examine the Foundation’s Pioneer Portfolio.  We will embrace the third once open proposal is launched .It is the fourth that intrigued me…. a strategy that I encounter daily in my entertainment life, but had not considered in my work.

Similar to the iPod app Pandora, which predicts what kind of music an individual will like based on the fundamental properties of the songs they have indicated they liked in the past, I am intrigued by the challenge of discovering what it is about the Pioneer team’s projects that makes them pioneering, in order to predict projects and ideas that the team should seek to support.

To turn patterns into information, I’ll start by going through the notes I took at TED, the words my colleagues shared, and the characteristics the other meeting attendees supplied: infrastructure, unconventional, unpredictable.

I’ll also go through the two years of data we've collected in our quest to objectively score our portfolio's success at attracting and supporting successful pioneering ideas/projects.  Even our crudest measures, such as when we just ask our examiners, "Is this pioneering?" why?  What is pioneering to you?

Through all of this, I’ll look for clues to the building blocks of the pioneering genome, then see how we can use that information to gain knowledge.

 

Measuring “Pioneer-ness” at TED

I'm thrilled to attend TED this week. In addition to being open to new ideas that might morph into fundable projects for RWJF, I’ll be expanding and refining my thoughts about measuring “pioneer-ness.” This means trying to distill a core definition of "pioneering" and validating this definition – seeking, in the end, a scale and/or indicators rwjf staff and others can use to objectively score the ideas we support.

I plan to collect data by having each RWJF program officer here rate presentations as "pioneering, innovative, interesting, or not that interesting" and by interviewing fellow attendees about how they make determinations about the ideas they're hearing.

As the week goes on, I may find I have a checklist I can use to score each idea.

 I may not.

If I had to answer the question today of "what is pioneering”—and how you measure it – I'd say, without taking credit for the language: 

“Pioneering ideas have potential for breakthrough solutions to emerging or persistent problems."

If I had to answer the question today, how do you make decisions about pioneering (vs merely innovative) ideas, I'd say:

“RWJF pioneer team members seem to know it when they see it.”

If I had to answer the question today of  "how do you measure ‘pioneeringness,"  I’d say:  

“I don't yet have good indicators, but a scale to measure "pioneer-ness" would surely include elements of newness, unexpectedness, risk (carefully defined),and  the potential for a leap in progress. These projects also have the potential to transform health care with out-of-the-box solutions.”

I'm not sure if I would include the elements of elegant or simple, but I'm expecting to be most blown away by ideas that I understand but never would have come to me.

I hope a few new ideas will come to me as well.

Update to original post: I’ve been asking each of my colleagues (and TED attendees I’ve interviewed) to rate the ideas presented as Pioneering/innovative/interesting.

I found that scale limiting, and have expanded to: Pioneering/innovative/important/interesting. Though something can be innovative, but not important technically, so I’m going to work with this scale until it breaks down.

Here are some words and concepts that are being associated with the concept of pioneering:

• (un)Predictability: However, it’s not always clear what’s better in terms of impact. Julie Taymor talks about the value of not knowing where you are going to end up, so I think that having a project that allows for unpredictable outcomes will have  more pioneering potential.
• Simplicity
• Understandable
• Done before?
• Tried before: This is a real challenge. I’ve started with a score of pioneering for more than one idea, until speaking with others and finding out that someone else has done this before.
• Redefine rules?
• Suggest an infrastructure?: This is likely to result in lasting social change (no need to define the type of change..maybe that’s unpredictable)
• Hypothesis driven?
• About discovery?

I’ll continue to hone this scale throughout the remainder of TED and will let you know how things shape-up after the conference. 

 

 

 

Innovative Ideas for Battling Adult Obesity at Invitational Choice Symposium

Last week, I went to Key Largo, Florida to attend the 8th Triennial Invitational Choice Symposium, hosted by the University of Miami and the University of Technology, Sydney.  Pioneer has had an ongoing interest in behavioral economics – also called choice architecture or “nudges” – which explores ways to influence people to make healthier choices.  You’ll recall that we sponsored the “Designing for Better Health” competition with Changemakers last year to identify health nudges. The conference convened researchers, psychologists, marketing folks and behavioral economists from around the world to meet together in small groups for three full days to present and discuss whatever they wanted. 

 

At the Invitational Choice Symposium, there were about 15 different groups that discussed topics ranging from marketing and politics to the intersection of perception, learning, thinking and feeling. My group, which was simply called “improving medical decision making,” brought together researchers with expertise in psychology, financial incentives, nutrition, law and economics to discuss how to improve medical decision making.…by physicians, nurses, patients and other actors in hospitals, medical offices, minute clinics, schools, at home and in the workplace.

 

Being that I work outside of the academy, I was invited by Dan Ariely and Ziv Carmon to join Kevin Volpp, Brian Wansink, Anup Malani, Barbara Kahn, Peter Ubel and others to provide a real-world perspective to the conversation. When the academics get too high up in the clouds, I was told, you should bring us down to think in a more focused way about how incentives can result in improved health and health care through improved policy or other tools to motivate and sustain favorable behaviors of providers, patients and others.

 

I don’t want to speak for the others, but I assume they were as gratified as I was for having the opportunity to spend so much time thinking and learning with those who had some of the missing pieces of the puzzles we were attempting to solve. We talked about LOTS of problems (conflict of interest, patient comprehension, adherence to medication) and lots of potential solutions (requiring cash payment, default second opinions, videos to change norms). The main issue that ran through the three days was adult obesity.  Though we  tried to leave the issue aside because we worried about wasting time on an issue that even Oprah can’t surmount, the fact remained that it was such a thorny behavioral problem that we couldn’t escape it.

 

In our discussion about how to address adult obesity, we talked about needing to understand why and how obese people become obese. Are they eating a lot at meals? (in which case, restaurants offering to serve half portions at 2/3 the cost of a full serving could provide a partial solution). Are they eating a lot when they are with their obese friends (then targeting interventions at social networks sounds promising). Are they eating the foods that are cheaper? (a fat tax could help). Are they eating the same amount as non-obese people, but just have a worse metabolism (need a miracle drug)? Are they eating because they don’t know how bad some things are for them or how good something are for them (calorie counts and other informational materials could help)?

 

The discussion dug in deeper to get at whatmight work to change eating habits.  Rules and restrictions? Financial incentives? Financial incentives to people’s friends?  Virtual incentives like those provided through the Farmville game? Points for good behavior redeemable the way frequent flyer/spender miles/points are? Making the world a Canyon Ranch? Limiting serving size by law? Shrinking plates?  Hiding appealing-looking food? Taking away people’s “heavy clothes” and buying them a new wardrobe to incentivize weight loss and maintenance?

 

Here is one idea that I feel enough ownership to share, though it was born of the insights of others: I think that a lot of people screw up their “good” day by eating something they didn’t really want.  Though I think that people who bring sweets to work and leave candy on their desk for people to nibble on have the best of intentions, free food is hard to pass up and good-looking food is a good way to start your day on a slippery slope.

 

What would it take to change the culture? To have co-workers consider it a rude thing to do to bring in cupcakes,  donuts, or cookies to a meeting, or put out chocolate when it is potentially damaging to someone else’s health? Would signs in the bathroom stall or conference room doors be enough?

 

At the conference, I accomplished the goals I set out to accomplish: to learn more about cutting-edge behavioral economics and decision science, and come away with an idea with “breakthrough potential” for possible future development by Pioneer.

 

I’ll expand more upon these ideas on future blog posts.

 

 

Making Decisions about Nurse Practitioners’ Scope of Practice

Dr. David Eddy, founder of Archimedes, recently visited the Foundation to present ARCHeS, a Web-based delivery platform that enables policy-makers and health leaders to use the Archimedes model to run their own virtual trials. Dr. Eddy demonstrated a prototype version of what users can expect to access via ARCHeS and previewed new functionality that will allow providers and decision makers to use the model to tailor care decisions for individual patients. Pioneer is supporting Archimedes to build ARCHeS.  

What struck me about ARCHeS was the opportunity it presented to make evidence-based policy decisions about nurse practitioners’ scope of practice that could potentially result in significant savings. Currently, those who advocate for nurse practitioners playing an expanded, autonomous role in delivering primary care point to seminal evidence showing comparable outcomes in patients randomly assigned to either nurse practitioners or physicians where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians. Though this research is not without its critics, it has been used successfully to convince many to see nurse practitioners as part of the solution to expanding access to primary care.  

Nevertheless, the debate around whether and how nurse practitioners’ scope of practice should be expanded and standardized nationally requires evidence that digs deeper into aggregate results. Policy makers need access to evidence that elucidates what nurse practitioners can do as well as physicians vs. tasks/responsibilities that should be left to physicians.  

For example, in his presentation, Eddy showed how ARCHeS, using evidence about both the cost and outcomes of nurse practitioners, indicates that having nurse practitioners administer shots to reduce cholesterol has a striking impact on the cost per QALY for a treatment option. Funders, including NIH, could use these criteria to prioritize funding condition/procedure-specific randomized control trials (RCTs) and other studies.  

To learn more about the implication of ARCHeS, I recommend reading a special report from Business Week entitled “Trimming Health-Care Costs Without Reforming the System,” which implies that the Archimedes model, when made accessible to policy makers and other decision makers, could lead to better decisions that could save billions in health care costs.

The promise of social network analysis

Nicholas Christakis’ new study on social networks and smoking cessation was published in yesterday’s New England Journal of Medicine. Using data from the Framingham Heart Study, Christakis and his colleagues reconstructed the social networks of more than 12,000 individuals and found that smoking cessation occurs in network clusters – the study also concludes that the chances of continuing to smoke decrease significantly for an individual when their spouse, friend or even sibling quits smoking.

The article, funded in part by the Pioneer Portfolio, is garnering a lot of attention in the media and stimulating many dinner table discussions. While the findings provide valuable lessons for those working in the field of smoking cessation, the study has implications well beyond smoking. Christakis’ work, reflected in this study as well as in the results he published last year on the influence of social networks on the spread of obesity, opens up a whole new way of exploring health behavior. I expect that over the next few days, weeks, months and years, policy makers and those advocating for social change will discuss how these findings can shape interventions and policies and researchers will clamor about how this innovative approach will expand the arsenal of tools used to help us understand and address some of our nation’s most challenging health problems.

Social Network Analysis, Obesity and Other Topics

I've been following with interest the reaction this week to the findings published in the New England Journal of Medicine on spread of obesity through social networks. While much of the discussion in the blogs and on the Web has been about the substance — whether obesity is, in fact, socially “contagious” (although the paper in fact hypothesizes that the spread of norms and perhaps behaviors may be the key) and has not always been accurate (the authors never, for example, suggest that discrimination against people who are overweight is either warranted or justified) — for my colleagues and myself at the Foundation, the chatter has been about the methods the researchers used to produce the findings through social network analysis.

It is not a new idea around here that social network connections are important to the spread of health and health care attitudes, behavior and status. Previous work funded by the Foundation and others suggests that understanding patterns and structures of social networks is as important to understanding health care systems and health behaviors as understanding the attributes of a given individual or care setting.

What is new to us is that researchers such as Nicholas Christakis, Robert Sampson, Peter Bearman, Thomas Valente and others are developing methods that transform a notion — that how a person behaves is dependent in large part on how that person is tied into a larger web of social connections — into an emerging science.

This science promises to improve our ability to 1) explore and understand the spread of health outcomes and behaviors — both good and bad — within complex, real-world social networks that evolve across time, 2) reveal new approaches to improve healthcare policy and practice.....and therefore to 3) inform the activities of those working to improve health and health care — including thousands of grantees RWJF has engaged in this work through out the U.S. (including, but not limited to those working to combat substance abuse, increase health care insurance coverage and meet other public health objectives).

Most immediately, we have funded* Nicholas Christakis and his colleagues at Harvard Medical School to continue their work building the science of social network analysis. By augmenting their current dataset, developing a new dataset, and continuing to innovate around the statistical methods necessary to produce rigorous findings, Christakis and colleagues will, we hope, produce new data and tools that can be used by other researchers interested in this area of intrigue to explore questions we haven't even conceived yet (and some we've been wrestling with for decades). My colleagues and I will continue to explore how the science of social network analysis can help us plan programs and evaluations of programs — particularly those that have as a purpose to improve the human capital of those working to improve the health and health care of Americans within our lifetime.

*sentence corrected August 10, 2007 to reflect the effective date of the grant.