This fall’s Foltyn Seminar brought together a leading expert in behavioral economics and key figures of community programs in Delaware to better understand how individuals make decisions and how those decisions can be influenced to improve health outcomes. Titled “Preventive Power: Using Nudges and Incentives to Improve Health," the seminar highlighted critical tactics for improving health throughout the U.S. using nudges, incentives, and food is medicine as a potential paradigm shift in improving health.

Led by keynote speaker Kevin Volpp, Mark V. Pauly presidential distinguished professor and director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, as well as scientific lead for the American Heart Association Health (AHA) Care by Food initiative, the seminar started by addressing prevalent challenges with healthcare in the U.S. Despite spending the most on healthcare compared to any other high-income nations, the U.S. is last on key health measures, including a 48^th ranking in overall life expectancy.

“In the first year following a heart attack, only 40 to 45% of insured patients take all of their cardiovascular medications,” Volpp declared. “We need to identify more cost-effective ways to improve health. It’s important to develop and test ways of deploying programs that change clinician and patient behavior as the final common pathway in health improvement efforts.”

Overcoming Challenges with Human Behavior

To lead to meaningful behavioral changes, the first step is understanding that simply providing people with information alone generally doesn’t result in the desired behavior change, as people are often focused on many priorities besides improving their long-term health. Through research by leading behavioral economists, it’s clear that people generally have bounded rationality and navigate the world using decision heuristics that simplify their decision-making process but often lead to less-than-optimal health choices.

“In designing programs, we need to think of the mind as a high-resistance pathway,” said Volpp. “Intervention program design needs to reflect that decisions are often made using behavioral reflexes that bypass making decisions using a deliberative cognitive process. This can be accomplished by being intentional about the defaults embedded within the choices people are presented with, the intentional use of well-designed financial and social behavioral incentives, and keeping things as simple as possible to maximize the chances of long-term engagement.”

By delivering defaults that automatically enroll people in a program (where they can opt out) as opposed to having people only enroll by actively opting in, participation rates rise dramatically. This has been evident across 401(k) plans, organ donor registration, and even cancer screenings. Utilizing approaches such as listing healthier foods first in a list or using 90-day vs. 30-day scripts for chronic medications can also contribute to improved health decisions. The goal is to make the healthiest choices easier for patients.  

Programs can be further enhanced by including social or financial incentives. For example, a 1.5-cent-per-ounce tax on sugar-sweetened beverages resulted in an overall 38% decrease in their consumption. Another study successfully leveraged loss aversion, social accountability, and variable reinforcement as part of a gamification program to encourage increased physical activities among friends and families. For programs to be successful in applying financial incentives, it’s important to keep them simple and provide amounts that are adequate to encourage behavior change.

“There are some situations that require higher incentives for success,” clarified Volpp. “Quitting smoking is a greater challenge versus increasing vegetable consumption. We have tested a variety of strategies using incentives of about $750 for smoking cessation, showing a tripling of quit rates in employer settings at 12 months.”

Volpp’s final point emphasized the importance of unhealthy diets as a major driver of premature morbidity and mortality in the U.S.

“Food is central to all health outcomes, from diabetes to kidney disease, arthritis, cancer, and more,” explained Volpp. “Despite this, only one in 10 Americans meets the recommendations for fruit and vegetable intake, and nine in 10 Americans ingest too much sodium. Americans consume an average of 60 pounds of sugar a year. Affordability of healthy food is a substantial challenge for many Americans, with lower-income seniors and families often struggling to afford healthy food while paying rent and filling scripts for needed medicines.”

In the past, the health system didn’t systematically address these issues to increase access to healthy food for high-risk individuals. It is possible, however, for some conditions like heart failure, that it would be highly impactful and cost-effective for healthcare insurers to provide subsidized access to medically tailored meals or other food is medicine strategies. This is aiming to be further amplified with the AHA Health Care by Food initiative through 23 randomized trials, 10 planning grants, and working with several states and private insurers to build sufficiently compelling evidence that insurers will want to cover Food is Medicine programs because they are as or more cost-effective than currently covered healthcare interventions.

Using Community Programs to Improve Health

Following Volpp’s presentation, five-minute lightning talks were led by Eric Plautz, community health worker with Food is Medicine at ChristianaCare, Kim Blanch, director of Community & Mobile Outreach at Beebe Healthcare, and Donna Paulhamus, director of the Nutrition Clinic at the University of Delaware. Each panelist highlighted how their unique community program was positioned to help improve health, especially for those who need it most throughout Delaware communities, by providing nudges and food as medicine. 

The seminar concluded with a panel discussion, featuring Volpp and the other three speakers, who responded directly to questions from the audience. Questions varied from better understanding the challenges and impacts of insurance coverage on programs, identifying strategies to enhance health studies for the future, to the potential benefits of including support systems like family members into the intervention process.

In final thoughts, each speaker shared reflections on how readers can make a difference:

• “What matters most is a true sense of wanting to work with individuals and finding your passion,” said Plautz. “Passion helps push us through the challenges, and there’s so much opportunity for more people to get involved. For patients, having someone who cares about them is one of the most powerful ways to help.”
• “Education, education, education,” declared Blanch. “Only 12% of Americans stated they were proficient in health literacy. We can’t assume people understand what we’re teaching them. So how can we tell it to them differently so it makes sense in their everyday life? Education is empowerment.”
• “The patient demographics seen in UD Health clinics are often different from those facing serious mental health issues,” explained Paulhamus. “If you only participate in experiential learning at UD clinics, you may not see our community projects. I highly encourage everyone to get involved with all UD programs and get a different perspective on all the ways we engage to meet the needs of our communities.”
• “Three big areas of need in terms of the healthcare system are dietitians, mental health professionals, and more effective behavioral changes in nutrition and more broadly in reducing cardiometabolic risk,” Volpp stated. “I encourage anyone looking to help with improving population health to consider volunteering to work with the American Heart Association.”