health care

Digital Health Coaching: how to create success stories

Author’s Note: A shortened version of this post was published on the Rock Health blog this week. Thank you to my co-author, Glennis Coursey for working on this article. 

Meet Mary. She recently decided she wants to get healthy and lose some weight.

So she signs up to work with a personal trainer. Mary likes the sessions but the high cost make them difficult to maintain. She decides to get some workout DVDs and be active on her own. Her sessions quickly start to taper off. She orders a dieting book but never gets past the first few chapters. Her kids give her a Fitbit. She buys a yoga mat.

Mary has almost everything she needs to be healthy. But none of the social support, encouragement, or accountability to actually be healthy.

Then, Mary signs up for digital health coaching.

What the heck is digital health coaching?

It’s no secret that working with a health coach can be a wildly effective behavior change strategy. Research consistently shows that health coaching increases medication adherence, decreases health care costs, enhances perceived happiness, and maximizes overall health related goal achievement (,,,). But the price and logistics aren’t always an option for many people.

Enter digital health coaches.

These are real human coaches who are able to scale their services to large groups of people all over the world using digital tools. When coaching services are combined with data from wearables and apps, coaches can provide almost instant feedback on people’s health choices. This feedback is superior to the feedback a user might get from an app alone because a digital health coach is trained to translate the data on both a social and emotional level. Presenting people with large amounts of data about their behavior isn’t always enough. But presenting data in a personally meaningful context can help trigger actionable change.

Several companies are exploring new and innovative ways to scale digital health coaching including MyFitnessPal, Kurbo Health, Omada Health, ThriveOn and Retrofit.

Efficacy data on digital health coaching is in the early stages, but here are some important lessons from two veteran digital health coaches on how to successfully hook people in creating long term change.

1 – Break cycles of failure.

Let’s go back to Mary. She’s just started working with her digital health coach.

Every time Mary hasn’t succeeded at getting healthy in the past, instead of blaming her diet book or Fitbit or health app, she’s blamed herself. Mary doesn’t think, “These products have failed me”. She thinks, “I have failed.”

Mary’s coach can work to understand her unique history and patterns of failure to support in her in breaking through failure.  How?

2 – Create a success story. Fast.

Almost immediately, Mary’s coach need to help her set a goal she can achieve. Common goals we hear from people starting a new digital health coaching program are:

  • I want a 6-pack.
  • I want to go to the gym five mornings each week.

Coaches can support these as long-term goals, but should quickly help people shift focus to habits and behaviors that have a high likelihood of success. Goals like:

  • I will decrease my waist size by one inch.
  • I will walk my dog around the block three times this week before dinner.

Immediate goal achievement is critical for self-efficacy. Self-efficacy, or a person’s belief in his/her ability to do something, builds over time with successful practice and directly determines a behavior change outcome.

Keeping people focused on the present and near future also increases likelihood of success. Rather than setting out to do 1000 sit-ups for the next year, set the goal to do 10 minutes of core exercises on Monday mornings for the next two weeks. If a person can do sit-ups for two weeks, they are more likely to do sit-ups for a month and so on. BJ Fogg’s Tiny Habits program teaches this concept of baby steps well. When she first started, Mary’s goal was to go to the gym five mornings each week. Instead, her coach worked with her to walk the dog around the neighborhood after dinner three times this week.  Keeping Mary focused on completing something “smaller” in the present and near future increases her likelihood of success.

3 – Provide an enjoyable reason to believe this time will be different.

Most people, like Mary, have been slowly gaining weight pound by pound for years. They often believe – and the diet and fitness industry often tells them – that change can happen fast. But building new habits takes time. Habits are socially, emotionally, and neuroscientifically very difficult to break because they are hard-wired into the habit default center of the brain. It is easier to create a new habit than break an old habit. And to create a new habit well we must find the joy in it.

One of Mary’s new goals is to follow the Mediterranean diet.

She’s been trying the diet long before she started digital health coaching. She’ll stick with the diet for a while, but then her old habits kick in and she’ll head to the bakery for an afternoon pastry.

Instead of focusing on breaking Mary’s established pastry habit, Mary’s coach encourages her to buy some hummus and carrots for her office so she can practice eating those during her afternoon snack break. The hummus she buys is at a market she loves to visit. She soon finds that eating the hummus and carrots make her more energized and notices she’s less tempted to head to the bakery. Her coach validates and celebrates her decision every time she chooses the hummus.

Mary starts to believe that working with a digital health coach is what she needs to learn how to create habits she can maintain. This time will be different. This period of coach-led, data-driven, dynamic experimentation is critical for putting users on a path to success.

4 – Personalize for long-term engagement.

Only after coaches have established social trust do they have the opportunity to really get to know the unique lives and challenges of the people they work with. Now that Mary’s had a taste of success, she’s beginning to trust that her coach can guide her in making better decisions.

One thing we hear over and over again is “I want to know that my coach or my program knows me.”  Social trust and personalization is needed for a successful coaching relationship, because

  •       Frustration results when people really want to do something but cannot;
  •       Annoyance results when something is really easy to do and people do not want to do it;
  •       Fear of failure is almost constantly present.

An example of the level of personalization digital coaches should strive for with the people they work with might be:

  •       Rather than: Have you walked for 30 minutes today?
  •       Instead: Hi Mary. Are you and Rover going walking along the river this afternoon?
  •       Rather than: What’s for dinner tonight?
  •       Instead: Hey Mary! What are you thinking about making for dinner tonight? I’m guessing your avocados are just about ripe by now…

Going Forward In Digital Health Coaching

This year we’ve seen a surge of business announcements related to digital health coaching: In February, MyFitnessPal announced it’s acquisition of Sessions. In April, Omada Health completed a Series B funding round of 23 million dollars. In May, Weight Watchers acquired online fitness startup Wello. In July, Kurbo Health announced that it raised $5.8 million to “use digital health coaches to help fight childhood obesity.”

Each of these companies leverage the power of technology to strengthen and scale human-to-human coaching relationships to make big impacts on people’s journey towards better health.

It’s not all about the technology, though. It’s about leveraging the power of technology to strengthen and scale the human-to-human relationships that can hook people better than an app ever could. Digital health coaches are the human force behind people’s journey to better, sustainable health.

 

U.S. Health Insurance: how the money flows

A brilliant research colleague of mine recently posted the following questions about U.S. health insurance companies:

  • How do these insurance companies work?
  • How does money move through the organization?
  • If we could follow the dollar …where does it go? Do they invest it? Cost is going up, but these companies are still making much money. How do they do that?
  • Who makes the decisions inside the organizations? What are their decision making processes?

I love this topic, and more and more about the economics of health care in this first year of Obamacare is unfolding every day. To understand how the money flows, let’s glance at a chronology of health insurance industry money.

Pricing. There are two basic types of health insurance pricing:

  • Community pricing
  • Actuarial pricing

Community pricing: economists look at a whole community to figure out what it costs to take care of that community. They then divide that total dollar amount by the number of people in the community. The resulting figure becomes the price per person for health insurance premiums.

Community pricing was the standard practice after World War II in the U.S. Back then the government left health insurance companies to run tax free; and it was a time when the average cost of insurance company administration was 5% leaving 95% of insurance premium dollars to be dispensed on health care. Back then premium prices were low – the sick and the healthy paid the same amount, but that didn’t bother anyone. Then, in the 1970s we saw an explosion of a) demographics and b) medical technology. People started living longer. Specifically, in the year 2000 as many people over the age of 100 were alive as were people over the age of 65 in 1965. The longer people live, the more likely they will need health care. But back in 1965, there were no CT scans nor super expensive medications. So booming demographics and expensive technology, along with c) laws that demand that more and more health conditions must be covered by insurance, drove health insurance premium prices sky high.

Actuarial pricing: economists look at an individual person to determine the risk of getting sick to price insurance premiums. In this case, healthy people have low premiums and sick people have higher premiums.

Obamacare is a hybrid of community and actuarial pricing. The theory is that if enough young, healthy people buy health insurance they do not use, it will offset the costs of paying for chronically sick people. We don’t know yet if this “economics of balance” will work ……

But back to actuarial pricing -> insurance companies figured out how to weed out the sick people by denying care according to pre-existing conditions. Denial of care practices evolved 1975 – 1992 as health care costs began to explode. Large scale HMOs became the popular practice by the early 1990s when Wall Street entered health care to financialize it as they did so by focusing on management practices. During this evolution, management/administrative expenses crept up from 5% to 35% of health care operating budgets. One year the head of United Healthcare was paid a salary of $1.2 billion dollars! Finally, the government intervened by passing a law that the maximum amount of health care premium dollars allowed to be spent on administration was 20%. Since then, regardless of how health care is priced, we have the 80/20 rule mandating that 80% (and in some cases 85%) of premium dollars must be spent on providing care.

Gaming the System. It was not just health insurance exectives that practiced greed & cheat during this time. Providers (hopsitals, doctors) responded to the management of health care by gaming the system: for instance, hospital administrators would tell doctors to discharge patients as soon as possible, and often before they were ready. Because the less time a patient spent in the hospital, the more profit for that hospital. And if a patient needed a CT scan during their stay, for instance, doctors were ordered to discharge the patient and re-order the test as an outpatient procedure. While doctors may have felt uncomfortable, they did what they were told because 1) they were rated by hospital administrators and 2) they figured the patient who left too early would come back, allowing the hospital to collect money for two admissions instead of one. Another popular trick for gaming the system was via hospital codes and prices: wildly inflated hospital prices, that in many places are still prevalent today.

Government regulators have been working to stop the greed, for instance via Medicare and Medicaid audits like the RAC audit  and ZPIC audit.

How Insurance Companies Make Money. There are two basic ways health insurance companies make money:

  • Premiums
  • Investments

When premium money comes into a health insurance company, it is referred to as a “loss” to set a mindset to avoid dispensing care. Health insurance companies try to minimize losses by setting up doctor panels and negotiating in-network contracts, for instance….practices that determine how much money a health insurance company pays providers for care (reimbursement). One such practice to determine health care reimbursement is called a Diagnosis Related Group (DRG). So let’s say it is determined that the cost of someone having a heart attack is $X. The health insurance company says to the hospital “We are going to pay you $X for a heart attack. Many heart attack patients who come in will experience complications that cost you more, and many other patients will experience easy recoveries that will cost you less, so it’s your job to decide how to manage the patients and practice medicine so you don’t go broke.” For this reason, doctors have been pressured to practice the cheapest medicine possible to maximize hospital profits by seeing as many patients per day as possible – a practice called fee-for-service. But Obamacare is forcing providers and insurance companies like Blue Cross  away from fee-for-service health care. And Aetna recently published information on health insurance premium rates to inform customers how they are using their money.

Again, 80% of the money within a health insurance company must be spent on care. If there is ever any money left over from that 80%, health insurance companies must give back to customers via premium rebate checks.

In terms of investments, many health insurance companies are putting their money into digital health. A recent RockHealth funding report showed 2014 digital health funding activity to date.  Whether or not these investments will be profitable is yet to be determined.

Moving Forward with Obamacare. Until Obamacare, individuals could only qualify for health insurance through employer work benefits, Medicaid (if financially qualified), or Medicare (if over the age of 65). This left millions of Americans without health insurance, creating a chaotic and uncontrollable economic landscape. Obamacare is rapidly spiking the number of people with health insurance, hypothetically balancing the economics. We don’t know yet. Like one insurance adjuster said to me “Pricing Obamacare health care plans is a bit like throwing darts: we don’t know yet how to make a profit until the many unknown accounting variables (are the newly insured paying their monthly premiums, how many are using state exchange plans vs. Medicaid, how many providers are accepting Obamacare contracts, etc.) settle in.” My guess is that at the close of 2014, once we have the chance to analyze Obamacare Year 1, insurance companies will come out to say they need to elevate premiums, while consumers and larger companies will demand more affordable health care.

A rise in E.R. visits explained by brain & behavior

The Wall Street Journal recently published a story that ER visits are on the rise despite rollout of the Affordable Care Act. 

Lawmakers wanted “to give the uninsured better access to primary-care doctors who could treat routine ailments and prevent chronic disease, with the intent of keeping patients out of the ER and lowering the cost of care”….but “Instead, the ER doctor group’s research and several other recent studies suggest that people who gain private and government insurance are more likely to seek emergency care.”

Of course we can point to a lack of sufficient primary care providers – we do not have enough here in the U.S. to handle all the newly insured. However, here’s a different perspective on why people are still seeking care in the ER:

Most uninsured people go to the ER when they need medical care. This is their habit. Because for years in this country, without health insurance, you could still seek medical attention in the ER. A habit is very difficult to break. In fact, an established habit is harder to break than forming a new habit is to make.

When you do a new behavior – let’s say, cook a meal you have never cooked before – your brain works hard to think about how to do it…how to follow the recipe, what temperate to set the stove at, etc. All that thinking takes place in the front of your brain, the prefrontal cortex. Keep in mind, the human brain is 1 – 1.5% of a human body weight, but takes up to 25% of the energy a human body produces to work. So any time you do something new, the brain function related to that new behavior consumes a lot of energy in the prefrontal cortex.

Once that behavior becomes familiar – meaning, you can cook that meal so easily you don’t need to think about the details – that thinking moves into the habit center of the brain, the striatum. Cooking that meal then becomes your habit. Habits, or defaults behaviors, are strongly wired in the brain and require little energy to maintain. This is why eating behaviors are so hard to change.

As we are learning, giving health insurance to people who are in the habit of seeking care in the ER will not be enough to break their habit. Going to the ER is their default behavior. I would bet that instead, they figure they can continue going to the ER and be covered. Their habit will now be paid for. These folks will not learn a new habit of going elsewhere until we design obvious and easy pathways for them to develop a new habit around seeking care.

Learning to go to a primary care provider is a new behavior for the uninsured who are now insured. Which means as health care designers, we need to figure out how to effectively tap into the prefrontal cortex of millions of people. I’d say we have important work to do!