Wellth, a digital health company based in New York, has developed a system that provides patients with daily financial incentives to improve their compliance with drug regimens. Low patient compliance results in significant issues in terms of patient health and increased financial costs. The company is particularly interested in targeting type 2 diabetes, congestive heart failure, post heart attack recovery, COPD, and asthma.
The Wellth system is geared towards high-risk, high-cost patients, and works by providing patients with daily incentives and reminders to take their medication. The patient sends a photo of their medication in their hand, to verify that they are successfully taking it, and receives a financial reward. Interestingly, the app starts a patient off with $150 for a 90-day period and if they comply with their regimen, they get to keep all the money. For every day that they don’t take their medication they lose $2. The idea is that this loss incentive is the best way to change behavior long-term.
See how the technology works here:
Medgadget had the opportunity to ask Matt Loper, CEO of Wellth, some questions about the technology.
Conn Hastings, Medgadget: Please tell us what motivated you to get into this area.
Matt Loper, Wellth: I have a family history of Type 2 Diabetes on my mom’s side. My grandfather and all three of his brothers lived their whole adult life struggling to manage their diabetes. Both of my mom’s siblings, Uncle Roy and Aunty Amy, were diagnosed with Type 2 Diabetes in their early 50’s. Over the years I have helplessly witnessed Uncle Roy not do a great job of adhering to his treatment and progressively get sicker. This non-compliance ultimately resulted in years on dialysis, a kidney transplant, and now full-time skilled nursing while being almost completely blind. On the other hand, Aunty Amy took control of her diabetes and health as soon as she was diagnosed, she is perfectly adherent to her care plan and has no complications since. So, you have two individuals with an almost identical genotype and diagnosis that end up with massively different outcomes and quality of life. The only difference between the two was their compliance behaviors over time.
Medgadget: Why is non-compliance such a huge issue? What kinds of consequences does non-compliance have for individual patients and society?
Matt Loper: Non-compliance exists because human psychology was imperfectly designed by nature. Our behaviors are motivated by immediate and tangible gratification, which is called Present Bias in Behavioral Economics. At some point, our ancestors were cavemen and cavewomen roaming the Earth. Those who were really motivated to find berries to eat right now were rewarded by being able to survive and live another day. Present Bias in today’s world leads to irrational and potentially harmful behaviors like medication non-compliance. A patient with Type 2 Diabetes who has been prescribed metformin knows rationally that taking their pills is going to help them a few years down the road but when they take a pill right now, they feel no different right now. On the other hand, they rationally know the candy bar sitting in front of them has too much sugar and they shouldn’t eat it but it feels great right now. So, as a result of our imperfect psychology, half of chronic disease patients don’t take their medications as prescribed and a study by the New England Healthcare Institute measured $300 billion of annual avoidable costs per year in the US simply due to medication non-compliance.
Medgadget: What is the Wellth approach to improving patient compliance?
Matt Loper: Our approach is pretty simple at a high level: give tangible and immediate gratification for the right behaviors through financial incentives. But in execution, it is extremely nuanced and difficult to get the great results we are demonstrating. To produce lasting improvements to adherence, you need to give the right incentive amount, with the right structure, communicated in the right way, and design a technology product that reinforces the behavior every time it happens to train a habit that sticks even after the incentive period ends. We designed our programs by reviewing hundreds of published behavioral economics and habit formation research papers and gleaning the most important insights from each one.
Medgadget: Why does this loss-incentive approach work better than just giving patients a small payment every time they comply?
Matt Loper: One of the key nuances to producing behavior change results is creating the right incentive structures. Another irrational cognitive bias that exists in human psychology is known as Loss Aversion. Loss Aversion dictates that humans are way more motivated by a potential loss of money than an equivalent gain and, in past studies, researchers have measured up to twice the behavior change from loss versus gain incentives. We credit our patients $150 up-front and then motivate them over the next 90-days to adhere to their care plan to avoid the loss of $2. This approach maximizes daily motivation through the fear of loss and, by endowing progress up-front, doesn’t require the patient to deposit their own money. So, we are able to generate very high enrollment rates and ongoing adherence rates in our patient population.
Medgadget: How has the system worked so far? Has patient compliance increased?
Matt Loper: We have been astonished by the impact that our evidence-based approach has had in real patient populations. Across diverse patient populations, income levels, disease states and age groups we are seeing reproducibly great results. 84% of the patients using our app are over 80% adherent to their medication. Especially telling is a population we work with of poor, elderly patients with Type 2 Diabetes with high A1c. On average, these patients remain 87% adherent to daily medications 6-months after being enrolled into our program! These results are truly remarkable, since the average adherence levels across all of these disease states is typically around 50%.
Medgadget: Do you envisage that patients will benefit from increased compliance after they finish using the app? Can the app change their behavior in the long-term?
Matt Loper: Yes, our app trains a habit over the initial 90-day incentive period and then keeps patients engaged and adherent afterwards. The potential for lasting habit formation from well-designed incentive programs is a crucial point that even the best researchers in the space are just starting to understand. There is a misperception in the market that when incentives programs end, the behaviors they promote end as well. A number of studies have shown that when a program is designed to habituate a behavior with repetitive reinforcement over 90-days, the behavior will last after the incentives end. Petry et al. published a study in the Journal of Clinical Hypertension in 2015 that showed patients remained 94% adherent to blood pressure medications three months after they had graduated from a 90-day incentive program (21% improvement vs control). Sen et al. published a study on a 90-day incentive program to promote the use of Diabetes remote monitoring in the Journal of General Internal Medicine in 2014. The results were even more impressive, with twice the adherence to remote monitoring devices (62% incentive vs. 27% control) three months after the incentive period ended. We are seeing similarly sticky habits with our patients who have been in our program for 6 months and demonstrate almost the same exact level of engagement and adherence as they did at the 30-day mark. We price our programs to guarantee significant ROI for our customers even by the end of first 90-day incentive period through lower hospitalizations and readmissions but then we keep patients compliant over the long term to continually drive better outcomes.