June 2015

In This Issue

NIH OBSSR, 5/21/15


Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

New York Times, Wall Street Journal, Washington Post, Reuters, NBC News, CBS News, Fox News, The Guardian, Los Angeles Times, TIME, The Philadelphia Inquirer, Huffington Post, US News & World Report, Business Standard, NPR, ABC, Tech Times, Yahoo Finance, The Business Journals, Knowledge@Wharton, LDI Health Economist, 5/13/15


Scott Halpern Elected to American Society for Clinical Investigation 

ASCI, 5/12/15


Justin Bekelman Awarded PCORI Grant 

Patient-Centered Outcomes Research Institute, 4/22/15


Kevin Volpp, MD, PhD: ACTS Distinguished Investigator Award for Career Achievement and Contribution to Clinical and Translational Science for Translation from Clinical Use into Public Benefit and Policy

Kevin Volpp, MD, PhD: NIH Matilda White Riley Award in Behavioral/ Social Sciences

Mitesh Patel, MD, MBA, MS:

Mitesh Patel, MD, MBA, MS
University of Pennsylvania Department of Medicine Holmes Award for Best Early Career Faculty Abstract

Recent Publications


Asking the Patient About Patient-Centered Medical Homes: A Qualitative Analysis. 
Aysola J, Werner RM, Keddem S, SoRelle R, Shea JA.
J Gen Intern Med. 2015. Epub ahead of print.

Electronic Devices and Applications to Track Physical Activity--Reply. 
Case MA, Volpp KG, Patel MS. 
JAMA. 2015.  26;313(20):2080. 

Workplace Wellness Recognition for Optimizing Workplace Health: A Presidential Advisory From the American Heart Association.
Fonarow GC, Calitz C, Arena R, Baase C, Isaac FW, Lloyd-Jones D, Peterson ED, Pronk N, Sanchez E, Terry PE, Volpp KG, Antman EM; American Heart Association. 
Circulation. 2015.  131(20):e480-97. Epub 2015.

Preference-adaptive Randomization in Comparative Effectiveness Studies.
French B, Small DS, Novak J, Saulsgiver KA, Harhay MO, Asch DA, Volpp KG, Halpern SD.
Trials. 2015 Mar 18;16(1):99.

Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care.
Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC.
JAMA Intern Med. 2015. Epub ahead of print. 

The Role of Behavioral Economic Incentive Design and Demographic Characteristics in Financial Incentive-Based Approaches to Changing Health Behaviors: A Meta-analysis.
Haff N, Patel MS, Lim R, Zhu J, Troxel AB, Asch DA, Volpp KG. 
Am J Health Promot. 2015. 29(5):314-23. 

Nighttime in the Intensive Care Unit. A Lens into the Value of Critical Care Delivery. 
Halpern SD. 
Am J Respir Crit Care. Med. 2015. 191(9):974-5.

Randomized Trial of Four Financial-incentive Programs for Smoking Cessation.
Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, Loewenstein G, Brennan TA, Asch DA, Volpp KG. 
N Engl J Med. 2015. 372(22):2108-17. 

Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies. 
Hart JL, Harhay MO, Gabler NB, Ratcliffe SJ, Quill CM, Halpern SD.
JAMA Intern Med. 2015. 175(6):1019-26. 

Post-Acute Care Use and Hospital Readmission After Sepsis. 
Jones TK, Fuchs BD, Small DS, Halpern SD, Hanish A, Umscheid CA, Baillie CA, Kerlin MP, Gaieski DF, Mikkelsen ME.
Ann Am Thorac Soc. 2015. Epub ahead of print.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. 
Kotloff RM, Blosser S, Fulda GJ, Malinoski D, Ahya VN, Angel L, Byrnes MC, DeVita MA, Grissom TE, Halpern SD et al.
Crit Care Med. 2015. 43(6):1291-325. 

Gout After Living Kidney Donation: A Matched Cohort Study.
Lam NN, McArthur E, Kim SJ, Prasad GV, Lentine KL, Reese PP, Kasiske BL, Lok CE, Feldman LS, Garg AX; Donor Nephrectomy Outcomes Research (DONOR) Network; Donor Nephrectomy Outcomes Research DONOR Network. 
Am J Kidney Dis. 2015. 65(6):925-32. Epub 2015.

An Observational Study of Decision Making by Medical Intensivists.
McKenzie MS, Auriemma CL, Olenik J, Cooney E, Gabler NB, Halpern SD. 
Crit Care Med. 2015. Epub ahead of print.

Insights from a Ten-Year, Prospective Study of Live Kidney Donors.
Nazarian SM, Reese PP.
Transpl Int. 2015. Epub ahead of print.

A Review of Standard Pharmacological Therapy for Adult aasthma - Steps 1 to 5.
Patel M, Shaw D.
Chron Respir Dis. 2015. 12(2):165-76.

Use of Wearable Monitoring Devices to Change Health Behavior--Reply. 
Patel MS, Asch DA, Volpp KG.
JAMA. 2015. 313(18):1865-6. 

Nudging Students Toward Healthier Food Choices- Applying Insights from Behavioral Economics.
Patel MS, Volpp KG. 
JAMA Pediatr. 2015. 169(5):425-6. 

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.
Reddy A, Pollack CE, Asch DA, Canamucio A, Werner RM. 
JAMA Intern Med. 2015. Epub ahead of print.

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Dear Colleague,


We hope you are enjoying your summer thus far! The June 2015 issue of the CHIBE newsletter focuses on two very important research studies conducted by CHIBE and LDI.

Our first story highlights recent findings related to a landmark CHIBE study on financial incentives and smoking cessation led by Scott Halpern. The study, published in the New England Journal of Medicine, enrolled approximately 2,500 CVS employees and family members and randomly assigned them into one of four smoking cessation programs or usual care. Participants who enrolled in any of the incentive-based programs were nearly three times more likely to quit smoking than those who received usual care alone. In addition, although participants assigned to the groups requiring an upfront deposit were more likely to decline participation, deposit programs led to nearly twice the rate of abstinence from smoking at six months among people who would have accepted either type of program. These findings were used to shape an innovative smoking cessation program for CVS Health employees that will launch this month.

The next story focuses on research led by LDI executive director Dan Polsky, which provides early evidence that the temporary "Medicaid bump" made it easier for enrollees in the low-income health insurance program to gain access to primary medical care.

This issue spotlights Alex Rees-Jones, CHIBE affiliated faculty member and Assistant Professor at the Wharton School. He describes his work at the intersection of psychology and economics and how this work relates to health and health care.

Please enjoy reading the June issue of the newsletter and be sure to check out our media citations and recent publications below. Also be sure to follow us on Twitter @PennCHIBE!



Kevin Volpp, Director


Scott Halpern, Deputy Director

Study: Incentives Help Smokers Quit - Effectiveness Varies By Program Design

Financial incentives can encourage people to adopt healthy behavior or drop harmful habits, but researchers continue to search for the most effective ways to offer these inducements. A recent University of Pennsylvania-led study of incentives for smoking cessation illustrates the complexity of the matter.

The study found that incentive programs were more effective than standard treatment in helping smokers to quit, but the degree of effectiveness varied based on how inducements of equal value were structured.

The research, published in the New England Journal of Medicine in May, examined a sample of more than 2,500 CVS Caremark -- now CVS Health -- employees and their friends and relatives, who were randomly assigned to one of four incentive programs or to a standard smoking-cessation regimen.

Two of the incentive programs were aimed at individuals and two were targeted at groups of six people. One individual program and one group program involved the opportunity to earn $800 in rewards for giving up smoking. The other individual and group programs required participants to make $150 deposits and offered them the chance to receive a refund and another $650 in potential reward payments if successful.

Standard stop-smoking care included educational materials and, for some participants, free access to nicotine-replacement therapy and a behavior-modification program.

All four incentive programs were more effective than standard care at helping participants sustain smoking abstinence through six months after the targeted quit date.


Scott Halpern MD, PhD

The pure rewards programs were more effective overall in achieving smoking abstinence because more people accepted that approach, according to CHIBE Deputy Director and lead author Scott Halpern, MD, PhD.  "However, we found that among people who would have accepted any program to which they were assigned, deposit programs were twice as effective as rewards and five times more effective than providing free access to nicotine replacement therapy or other aids to stop smoking," Halpern said.

Ninety percent of those appointed to the rewards programs accepted their assignments, while only 13.7 percent of participants accepted assignments to the deposit programs, according to the study, which involved several Penn researchers, including CHIBE Director Kevin Volpp, MD, PhD, Carnegie Mellon University Prof. George Loewenstein, and CVS Health Chief Medical Officer Troyen Brennan, MD.

Total costs spent per successful participant were lower in the deposit-based programs than in the pure-rewards plans.


"The trick is to modify deposit programs so that they become more effective in the future," Halpern said. People will do more to avoid losing $150 than to gain $150, he said. Now researchers need to find ways to nudge people into signing up for deposit incentive programs, he said.

The researchers suggested that future employee smoking-cessation programs be designed to require deposits smaller than the $150 used in the trial. The findings shaped a new CVS Health employee smoking-cessation program called "700 Good Reasons" that, as of June 1, 2015, requires participants to make a $50 up-front deposit. If these employees stop smoking for a year, they will earn $700 plus reimbursement of the $50.


These programs are important because smoking remains the leading cause of preventable illness and death in the United States more than a half century after the U.S. Surgeon General's initial report on its harmful effects, with 18 percent of Americans smoking regularly. Furthermore, the best available estimates suggest that employing a smoker costs several thousand dollars more each year than employing a non-smoker, the researchers wrote.

To the researchers surprise, no significant differences were found in the effectiveness of the group-focused and individual incentive programs, Halpern said. People tend to be motivated by social comparisons - a dynamic that might have been thwarted by the fact that group members didn't know each other before the study, he said.


Halpern and CHIBE founding Director Kevin Volpp, MD, PhD, are co-leading another trial to compare a straight rewards program with a virtual deposit program. "That's one of the most exciting future directions," Halpern said. He's also interested in developing interventions for people who are the hardest to change - those who heavily discount the future, or worry the least about what happens to themselves in the long term.


- Dinah Wisenberg Brin

Research: Medicaid Boost Tied to Better Physician Appointment Availability

Increased Medicaid reimbursements to primary care physicians in 2013 and 2014 - a key Affordable Care Act requirement -- appeared to significantly expand appointment availability for patients enrolled in the government program without creating longer wait times in doctors' offices, according to a University of Pennsylvania study.

The research, published in January in the New England Journal of Medicine, provides early evidence that the temporary so-called Medicaid bump made it easier for enrollees in the low-income health insurance program to gain access to primary medical care, the authors concluded.

"I think that there are a lot of doctors who are more than willing to see Medicaid patients," but in states that pay $50 or $60 for a patient visit, it doesn't make sense for physicians to do it. "For $100 a visit it does," said Daniel Polsky, Ph.D., executive director of Penn's Leonard Davis Institute of Health Economics, who led the Penn and Urban Institute study.

The ACA - the sweeping U.S. health insurance overhaul -- used federal funds to increase Medicaid payments to Medicare levels for two years for certain providers and services. The goal: improving primary care access for growing numbers of enrollees in Medicaid, a federal-state program for lower-income and disabled Americans that has expanded under the law.


When the federal provision expired at the end of 2014, only a few states opted to fund an extension as there was still uncertainty as to whether the policy had its intended effect. "This study provides evidence the policy works," Polsky said.


Dan Polsky, PhD

He and colleagues studied appointment wait times and availability in 10 states for two time segments: November 2012 through March 2013, and May 2014 through July 2014. Field staff participating in the research posed either as Medicaid enrollees or privately insured patients seeking first-time primary care appointments.

The researchers found that for Medicaid patients, appointment availability increased by 7.7 percentage points, to 66.4 percent from 58.7 percent, between the two time periods.

"The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10 percent increase in Medicaid reimbursements," the study said. "No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups."

Polsky said the results were "quite surprising," and that initially researchers thought the study would focus on difficulties in implementing the Medicaid rate bump. The 7.7 percentage point increase, he said, amounts to an additional physician available per every 13 or 14 physicians.

"That's a big number," Polsky said. With about 40 percent of doctors previously sitting on the Medicaid sidelines, he explained, it's important that so many decided to participate. "I think that's a huge effect."

Having more doctors see Medicaid patients didn't appear to have consequences for other patient populations, according to Polsky.

While federal support for the Medicaid payment increase expired, 15 states decided to continue paying higher rates, according to Polsky. Ultimately, it will be up to politicians as to whether to continue using taxpayer dollars for this purpose, he said.

Researchers plan to go back into the field, into the same 10 states, at the end of this year or in early 2016 to see if appointment availability declined in places where the temporary boost expired. Only one of the 10 states studied maintained the higher reimbursement, Polsky said.

"It would be a finding that would be very much indisputable if appointment availability went back down," he said.

- Dinah Wisenberg Brin 

Researcher Spotlight: Alex Rees-Jones, Ph.D.


Alex Rees-Jones, PhD
Alex Rees-Jones, Ph.D., is an Assistant Professor at the Wharton School at the University of Pennsylvania and a CHIBE Affiliate Faculty member. His research focuses on using psychological data and psychological models in economic applications to promote policy improvements. Alex works on a variety of topics within this broad field, but recently he's been particularly focused on using psychological models to better understand citizens' responses to taxation and tax incentives. 


How did you come to work at the Wharton School?

I conducted my graduate studies in economics at Cornell, working with a great group of behavioral economists there. After my time at Cornell, I spent two years in Cambridge, MA, working at the National Bureau of Economic Research. While there, I was mainly working on studies of economic applications of happiness data and research involving the psychology of response to taxation. I was then fortunate enough to get an offer to join the OPIM group at Wharton. As I'm sure everyone associated with CHIBE knows, Wharton has a fantastic group of researchers working at the intersection of psychology and economics, so as far as I'm concerned it's the perfect place to be! 


Tell us a bit about your work on psychological factors influencing taxation. 

In graduate school I became interested in applying a common model from behavioral economics, called "prospect theory," to tax settings. This theory has a number of features, but a main one is "loss aversion," or, the idea that people care a lot more about a dollar when it's making a loss smaller instead of making a gain bigger. This is a particularly intuitive idea when thinking about how people respond to their annual tax bill. It suggests that if we compare people owed a refund (facing a gain) and those who owe money to the IRS (facing a loss), people facing a loss would be predicted to "care more" about improving their tax bill. Therefore, loss aversion would predict that taxpayers facing a loss would be more motivated to take steps to reduce their taxes-doing things like claiming tax credits and deductions, or even pursuing tax evasion. I looked for evidence of these (and other) predictions in a large panel of tax return data, and found that the distribution of tax payments does appear to be influenced by this type of behavior. 

Seeing loss aversion in action in a high-stakes setting is intrinsically interesting to me, but more importantly, these findings could potentially be directly useful for policy purposes. Knowing a bit about the structure of people's psychological reactions to taxes can be quite helpful for thinking about how we want to design the tax system, and tax incentives.


How might your tax research apply to issues related to health and health care?


More and more over time, taxes are used to shape people's health behaviors. For example, penalties administered through the tax system are an important part of the insurance incentives laid out by the Affordable Care Act. Additionally, taxes are regularly implemented to help control the demand for a variety of unhealthy things, such as cigarettes or sugary drinks. When we're thinking about tools available to policy makers for shaping health behaviors, I'd say that taxes are among the most important, and most useful.


Have you done any work at the intersection of health and taxes?


In some ongoing work with my coauthor, Dmitry Taubinsky, we'll be able to look at those types of issues a bit more directly. In a series of studies that we fielded this spring, we collected extensive information about taxpayers' knowledge of the tax code, as well as consumers' attentiveness to sales taxes. We'll be testing a rich set of hypotheses about the psychology that governs perceptions of, and attention to, taxes. But in particular, we'll be able to see how some of the "mistakes" that arise in response to taxation are associated with various health behaviors, such as insurance status, smoking status, or soda consumption. This study is still an active work in progress, so I don't yet know the answer to those questions. But we hope to be able to say more soon about how suboptimal response to taxation is associated with unhealthy behaviors, and how we might be able to use our knowledge of this psychology to improve the efficacy of the tax-based incentives we use in health settings.

New Research Initiatives


Pragmatic Randomized Trial of Proton vs. Photon Therapy for Patients with Stage II or III Breast Cancer
Principal Investigator: Justin Bekelman, MD

The Radiotherapy Comparative Effectiveness (RADCOMP) Consortium will conduct a pragmatic randomized clinical trial in which 1,716 patients with stage II and III breast cancer involving lymph nodes under the arm or above the collarbone will be randomized after surgery to either proton therapy or photon therapy, the current standard treatment. Patients will be followed to determine differences in heart problems, cancer control, and health-related quality of life (HRQOL) after treatment. 

Funder: Patient-Centered Outcomes Research Institute