JULY 2018
The Healthy Nudge
Welcome to The Healthy Nudge . This month's edition of our newsletter will recap the work of our faculty and trainees at the recent AcademyHealth Annual Research Meeting ( #ARM18 ) in Seattle. Congratulations to CHIBE Steering Committee member Mitesh Patel, MD, MBA, MS on winning this year's Alice S. Hersh New Investigator Award !

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Loss Aversion and Social Pressure in Physician Pay-for-Performance (P4P)
The first randomized trial testing principles of behavioral economics in a physician pay-for-performance (P4P) clinical setting won a " Best Abstract" award in the Payment and Delivery Systems category at the AcademyHealth ARM. The study, entitled " A Pragmatic Policy Trial Testing Larger Bonus Sizes and the Behavioral Economic Principles of Loss Aversion and Social Pressure in Physician Pay-for-Performance," was led by CHIBE Associate Director Amol Navathe, MD, PhD.
At a poster session during AcademyHealth's ARM, Assistant Director for Research Operations, Laurie Norton, MA, presented a three-arm, pragmatic RCT that evaluated the impact of monitoring medication adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. The study found that "electronic pill bottles and text messaging programs to improve medication adherence may need to be replaced by or supplemented with other strategies in order to improve blood pressure among hypertension patients."
Use of Individual Provider Performance Reports by U.S. Hospitals
In another poster, CHIBE trainee Joshua Rolnick, MD, JD (profiled below) and colleague Kira Ryskina, MD presented the results of their recent study modeling how the odds of individual provider performance use differs as a function of hospital characteristics, including ownership, geographic region, teaching versus nonteaching status, size, expenditures per bed, proportion of patient days covered by Medicaid, and risk-sharing models of reimbursement.
Blog Spotlight
Designing Medicaid Health Incentives
CHIBE affiliated faculty member Charlene Wong, MD led an AcademyHealth ARM panel in which investigators discussed the latest evidence on the impact of incentives on healthy behaviors among Medicaid beneficiaries. As a number of states experiment with health incentives as an element of their Medicaid programs, our recent blog post sums up the panel's findings.
September 17 - 18, 2018
University of Pennsylvania
  • Assemble stakeholders from institutions that have launched or are interested in launching a nudge unit within their health system

  • Share insights on lessons learned from existing nudge units in health care

  • Engage in a design session to help programs outline important next steps at their health system
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 CHIBE Profile
Trainee Joshua Rolnick, MD, JD conducts research as a National Clinician Scholar through the Fostering Improvement in End-of-Life Decision (FIELDS) Program, a partnership between CHIBE and the PAIR Center at Penn. Rolnick attended AcademyHealth's ARM, presenting posters on hospital use of individual provider performance reports and the association of location of death with patient characteristics and quality of life.
How did you become involved in the field of behavioral economics and end-of-life care?
My interest in end-of-life care grew out of my clinical experiences, first as a resident and then as a hospitalist. Working as a hospitalist at a safety net hospital, I saw many seriously ill patients who had never had any form of advance care planning. Sometimes, they had no family or friends, and were too ill to make their own decisions. By default, the health system would provide aggressive end-of-life care that was not necessarily driven by the wishes of patients. Individual clinicians had good intentions, but the system was not serving patients well.
Behavioral economics was not a focus of mine until I came to Penn. However, I did have an interest in cognitive science, and I had also taken a seminar in behavioral economics and law while a law student. The appeal of applying behavioral economics to health is that health systems can apply evidence from behavioral science without changing laws. Many other suggested applications of health services research to the law would require a literal Act of Congress.
At the AcademyHealth ARM, you presented a poster describing your research on the association between location of death and patient characteristics and quality of life. What were your main takeaways from this work?
  Location of death has become a common marker of quality in end-of-life care, with the objective of having patients die at home rather than in a hospital. Without a doubt, this is a worthy goal in many situations. However, for all the attention on this topic, there is actually not a large body of research on how the patient and family experience varies by site of death. This is a small study of a nationally representative Medicare population. However, it is consistent with the idea that “global” measures of the end of life experience (e.g. overall care, sense of being treated with respect, etc.) are highest for patients who die at home. At the same time, there is a suggestion that care for symptom management may sometimes be better in inpatient hospice.
I caution to add, however, that there are many unmeasured differences between patients who die in home as opposed to acute care hospitals and post-acute settings. In addition, the small sample size of this research limited inference. This study is a bit of a teaser for a larger study I am finishing that looks in greater depth at the patient and family experience in acute care for veteran patients who die in VA acute care hospitals. 
You have worked in global health in the past. Do you see yourself applying behavioral economics in an international setting in the future?
I do have an interest in returning to global health at some point in the future. I think there are many opportunities to apply some of the topics and techniques used to study U.S. health care, such as behavioral economics, to improving health services research in the developing world. I also think there is a need for more research comparing health care in developed countries, including end-of-life care.
New Publications

The Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania conducts behavioral economics research aimed at reducing the disease burden from major U.S. public health problems. Originally founded within the Leonard Davis Institute of Health Economics , our mission is to inform health policy, improve healthcare delivery and increase healthy behavior.
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