Facing the Healthcare Crisis
Content
Facing the Healthcare Crisis
The Case for a 21st Century Behavior Change Paradigm
April, 2011
By Robb Smith
Chief Executive Officer
Facing the Healthcare Crisis
Chrysallis, Inc.
Introduction
Healthcare is in a crisis because a majority of healthcare spending and
healthcare inflation is driven by chronic conditions caused by unhealthy
lifestyles. It will remain so until a paradigm of mass personalized
behavior change is adopted that can solve the “complex adaptive
problem” of human change. Successful long-term human change
requires an equally adaptive support paradigm that enables learning and
real-time experimentation to continually close the gap between our
understanding of behavior in a theoretical way and the outcomes we’re
achieving in diverse and complex real world settings.
________________________
THE MODERN HEALTHCARE SYSTEM IS UNDER ASSAULT
It is expected to care for, repair and then pay for the massive damage being
inflicted by unhealthy individual behavior of every kind, in every setting, for
every individual. Employers, insurers and taxpayers – the three primary payer
groups – will continue to get crushed by a set of health conditions with
overwhelming cost trajectories, estimated to grow in the U.S. to $4.5 trillion
and nearly 20% of U.S. GDP by 2019. Nearly 80% of the overall spending and
inflation is accounted for by a handful of chronic conditions such as heart
disease, cancer, and diabetes driven in turn by a handful of lifestyle factors –
such as obesity, smoking, inactivity, and stress. And yet, despite
overwhelming evidence of significant ROI from preventive health and wellness
support, prevention continues to be criticized by funders because it is
ineffective at changing peoples’ daily behavior.
CALL FOR A NEW PARADIGM
To say the current global healthcare paradigm is not up to the task before it is
an understatement: trying to address the totality of a massively complex
biological, psychological, social, economic, and behavioral dynamic with an
acute care model at the tip of the spear, a chronic care model in the middle
and a one-size-fits-all preventive care model at the base of the pyramid will not
work. The U.S. Department of Defense, with their recently articulated principle
of “total force fitness,” is at the forefront of defining what a new paradigm will
need:
Achieving total force fitness involves … a system that addresses
an integrated whole person, including family, social, physical and
spiritual aspects … used in an integrated fashion for continual
process improvements… Such evaluations will also require a new
paradigm of research that uses information systems for rapidly
tracking components of total force fitness… Such an integrated
paradigm includes contextual understanding of person-specific
variables, uses innovative approaches based on rigorous methods
of empirical evaluation, and should narrow the gap between
science, health care, and training. We cannot sustain our force by
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staying within the present paradigm.
They are not alone. Other experts are also calling for ubiquitous, personalized
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and integrative preventive health that places the patient at the center of care
and accounts for a whole spectrum of physical, emotional, social, nutritional,
psychological, spiritual and environmental factors. At the heart of this
integrated, primary preventive health model is a requirement to achieve
sustainable behavior change across large-scale, heterogeneous populations at
a cost that is affordable to payers – a "holy grail" that has yet to be achieved.
Based on extensive research integrated from a wide variety of disciplines, we
believe that a pervasive, adaptive and mass personalized behavior change
ecosystem is necessary to change healthcare cost and outcome trajectories.
The behavior change support paradigm we call for will require a
comprehensive “whole-person, whole-system” view that meets these
requirements:
1. Everywhere and Always-On Support
2. Collaborative Real-Time, Real-World Research
3. Mass Personalized to Each Participant
4. Contextually-Adaptive, Whole Life Support
5. Strategic ROI for Payers
Anything that falls short of changing the behaviors of millions of people,
behaviors that are creating the chronic conditions in the first place, will not fully
alleviate the human suffering, the cost waste, and the loss of economic and
energetic productivity from a majority of our population. Even if we make
progress through new payer structures, by moving to greater care
management, achieving better chronic management modalities, cost-shifting
to consumers, or any other structural change in the current paradigm, they are
merely workarounds. The base of the pyramid problem will remain: we have to
enable a new paradigm of helping people to change behavior, at-scale, across
diverse populations so that we achieve real and lasting outcomes in health,
well-being and productivity.
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Our Lifestyles Are Killing Us
Unless and until we find a way to attack the healthcare problem costeffectively at the very base of the pyramid – the World Health
Organization estimates that 80% of heart disease, stroke, type 2
diabetes and 40% of cancer would be prevented through better diets,
more exercise and not smoking2 – costs and poor health trajectories
from the current paradigm of acute care and chronic care management
will continue to grow unabated.
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DAILY BEHAVIOR IS THE BASE OF THE HEALTHCARE PYRAMID
Healthcare concerns the ongoing functioning of the body, and what we eat,
what we feel, how much stress we’re under, how much exercise we get, and
how much sleep we get are among the basic building blocks of a healthy
lifestyle. And on each of these measures the population trajectories are getting
worse.
Rates of obesity have been rising for the past 30 years, and though they may
be beginning to stabilize, as of 2008 68% of adults in the US are
overweight (BMI>25) and half of those, or nearly 34% of the adult
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population, are clinically obese (BMI>30). We’re getting less sleep
By 2020 almost half of the
than we used to, with Americans who report sleeping eight or more
entire population of the
hours a night on weekdays declining from 38% in 2001 to 26% in
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United States will have at
2005; lack of sleep is indicated as a causative factor in obesity due
least one chronic condition.
to changes in appetite regulation, food cravings, increased bodymass index, decreased glucose tolerance, and increased insulin
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resistance. Our daily net energy balance also seems to have
gotten worse with higher per capita caloric availability, increased
consumption of fast foods and soft drinks, larger portion sizes, and more time
spent watching television. Fully 60% of the U.S. population does not engage in
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regular physical activity and 25% are completely sedentary. On top of all this,
more than 43 million Americans smoke cigarettes, which alongside obesity is
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one of the top drivers of chronic healthcare costs.
Approximately 40% of all deaths in the United States are premature due to
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unhealthy lifestyle choices (smoking, diet, alcohol and drugs) and unhealthy
lifestyle is the primary contributor to heart disease, cancer, stroke, respiratory
disease, and diabetes, which collectively account for 70% of all deaths (e.g.,
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more than 1.7 million people in 2005). , More than 125 million Americans had
at least one chronic condition in 2000, which is expected to grow to 157
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million Americans by 2020. By 2020 almost half of the entire population of
the United States will have at least one chronic condition.
WE’RE STRESSED OUT
The American Psychological Association reports that money and work
concerns account for very significant stress in 76% of adults in 2010, and that
while 69% place a priority on managing stress only 32% believe they are doing
a very good job of managing it. Adults place a high priority on several aspects
of overall well-being, including getting enough sleep (62%), eating healthy
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(64%) and being physically active (60%), but in each case only a fraction
believe they are effective in doing so (25%, 30%, and 29% respectively).
Adults cite a lack of willpower (29%) as the most common reason for not
adopting healthier lifestyle changes. Making matters worse, in 2010 almost
40% of adults report that they manage their stress levels by watching more
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than 2 hours of television every day.
OUR LIFESTYLE BEHAVIORS ARE MULTIFACETED AND DYNAMIC
What is clear is that our lifestyles, health outcomes and behaviors are not
single variable systems but instead constitute a complex adaptive system
(e.g., physiology and behavior impact health, our health impacts work
performance and stress levels, our stress impacts behavior and sleep, and so
on the cycle goes). With the complexity inherent in changing health behaviors,
where each factor potentially bears on all others, it is not surprising that longterm trajectories are bad and getting worse.
Healthcare Cost Trajectories are Shockingly Bad
Chronic conditions caused primarily by poor lifestyle and behavior
choices account for a majority of overall healthcare inflation, a majority
of overall healthcare spending, and hundreds of billions of dollars
annually in additional indirect costs to individuals, employers, taxpayers
and society.
________________________
CONFRONTING THE FULL COST OF OUR LIFESTYLES
Unhealthy behaviors alone
may add another $1.33
trillion in annual healthcare
spending by 2019.
Total U.S. healthcare spending is expected to grow from $2.5 trillion in
2009, or 17.3% of GDP, to $4.5 trillion by 2019, or 19.3% of GDP.
Updated estimates from the Center for Medicare & Medicaid Services
project annual growth in healthcare spending from 2010 to 2019 at 6.3%
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per annum, and if recent history is a guide, then most of this increase, or
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66%, will be attributable to unhealthy behaviors, and in particular obesity.
Chronic conditions alone accounted for 78% of all healthcare spending in
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1998, which if projected forward in constant terms translates into $1.95
trillion in 2009. The major chronic conditions and their causative lifestyle
behaviors represent a devastating toll in human suffering and drag on U.S.
national annual economic output:
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• Obesity accounts for $147 billion in direct medical costs annually, not
counting indirect costs for absenteeism, lost productivity or other costs
borne by employers.
• Smoking accounts for $193 billion in direct medical costs and lost
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productivity annually.
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• Physical inactivity accounts for $201 billion in direct medical costs.
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• Diabetes accounts for $218 billion in total costs in 2007, and as much
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as 80% of type 2 diabetes might be attributed to inactivity and
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overweight/obesity.
• Cardiovascular diseases, including heart disease and stroke, account for
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a staggering $480 billion in direct medical costs and indirect costs.
• Work-related stress is estimated to cost U.S. employers more than $300
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billion annually on absenteeism, lost productivity and health claims, and
employees who are feeling high stress have 46% higher total healthcare
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expenditures than those who don’t.
• Mood disorders are estimated to cost more than $50 billion in lost
productivity.
The implications of the current healthcare cost and lifestyle data is clear:
chronic conditions caused primarily by poor lifestyle and behavior choices
account for a majority of overall healthcare inflation, a majority of overall
healthcare spending, and hundreds of billions of dollars annually in additional
indirect costs to individuals, employers, taxpayers and society.
AND THE SITUATION IS POISED TO GET WORSE
With the passage of the Patient Protection and Affordable Care Act (i.e.,
“Obamacare”) the current healthcare paradigm is heading for trouble, with 35
million or more new patients coming on to insurance rolls in the next 5 years
with no material change in the underlying supply of medical care. We are
heading either for even more healthcare inflation or care rationing, and perhaps
both, and the current acute care model will likely have to change. Preventive
care will increasingly be on the strategic critical path for both providers and
payers, including employers. Under the accountable care organization models
(ACOs) contained in PPACA, providers will be paid increasingly on efficiency of
care rather than volume of care, which will incentivize efficiency-based
preventive care and a move away from volume-based acute care. On the
payer side, with "medical loss ratios" (MLRs) now capped at 85% for large
insureds, it is clear that a move to preventive care that reduces long-term
direct and indirect costs is also now on the critical path for payers.
The data make an overwhelming case for attacking the lifestyle problem by
moving healthcare resources and attention to health promotion through
primary and secondary prevention. Primary prevention seeks behavior and
lifestyle changes that reduce the likelihood that health problems ever occur in
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the first place and compares to secondary prevention, which is aimed at
trying to identify the early onset of diseases and then manages their severity
and progression (an effort that became associated with the disease
management industry of the past decade). If the case is so compelling, why
aren’t we doing it?
THE LESSON FROM EMPLOYERS
Sitting on the front line of the healthcare crisis, the lessons from employers are
instructive. A national survey of large employers in the U.S. in 2010 reported
that of eleven possible threats to maintaining affordable health coverage for
their employees, the top-rated threat was employees’ poor health habits, with
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Healthy-lifestyle behavior
change came in dead last
with only 6% of vendors
rated by employers as
highly effective and a full
2/3 of vendors rated as not
at all or only slightly
effective.
67% of employers citing it as the top threat. (The third most prevalent threat
was “underuse of preventive health services.”) And when asked what the top
obstacle to changing employee health-related behaviors, employers cited “lack
of employee engagement” by a margin of nearly 2:1 to the second-rated
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obstacle (“lack of financial incentives for participation”). The employer
picture is clear: they see that behavior change is the linchpin of rising
healthcare costs, and yet employee engagement is the top obstacle to
serious behavior change efforts. Poor employee engagement is not
surprising: many preventive healthcare efforts treat adults like patients that
need to be cared for rather than engaging them on their own terms, in the
issues that people desperately want to change in their own lives.
Employers are demanding better approaches to behavior change but
aren’t getting it. In the same survey when they were asked to rate the
performance of their healthcare vendors across a spectrum of 8 factors of
success, healthy-lifestyle behavior change came in dead last with only 6%
of vendors rated as highly effective and a full 2/3 of vendors rated as not at
all or only slightly effective. Despite efforts by commercial wellness vendors to
promote their services’ return-on-investment to employers, current
approaches are failing, which is why 83% of companies had recently
revamped or expected to revamp their healthcare strategy in 2010, up from
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59% in 2009. Employers remain highly skeptical of ROI claims from wellness
companies.
The Hardest Scientific Problem in the World?
Poor behavioral outcomes reflect the complexity of the problem, and
despite decades of research and progress on many theoretical fronts to
understand various components of behavior change, the reality on the
ground suggests we cannot consistently operationalize behavior change
across diverse populations.
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BEHAVIOR CHANGE IS COMPLEX
One social scientist has been quoted as saying that changing health behavior
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“is one of the most complex tasks yet confronted by science.” Evidence
suggests he may be right: some reports show that 50% of people cannot
sustain even a straightforward prescription course. Remarkably, 6 of 7 people
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will not change even when lifestyle changes may prevent death. And yet,
despite the daunting statistics, the efforts of behavioral heath scientists and
practitioners over the past several decades have been extraordinary in
illuminating the full scope of the behavior change challenge.
CURRENT MODELS OF BEHAVIOR CHANGE
Behavior change research is a multi-disciplinary affair involving insights and
theoretical contributions from psychology, sociology, economics,
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neuroscience, medicine, marketing, semiotics, philosophy and dozens of other
disciplines. There are not only a huge number of potential variables
interdependently interacting across the life condition of a given participant in a
change process, there are also three different levels of analysis and
intervention: individual factors and processes, social factors and processes,
and population factors and processes. Behavior change theories, by
necessity, reflect individual, intrapersonal behavior (e.g., Health Belief Model,
Theory of Reasoned Action, Transtheoretical model, Precaution Adoption
Process Model etc.), interpersonal dynamics (e.g., Social Cognitive Theory,
social networks, social support etc.) and large community health behaviors
(e.g., Diffusion of Innovations, Media Studies Framework, Communication
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Theory etc.).
From NIH’s Theory at a Glance (see endnote)
Not surprisingly the field has a diverse and fragmented theoretical foundation:
in the mid-1990s a meta-study revealed that within the 526 academic behavior
change papers reviewed there were 66 different theories and models of
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behavior change being used. There may be even more today (we argue
below that perhaps this is to be expected).
Despite a large and fragmented landscape of theories – many of which overlap
in significant ways and are complementary to each other – interventions have
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begun to converge around key areas of focus:
• Change initiation factors (e.g., self-efficacy, expectations of benefits and
costs, preparedness for change)
• Self-regulatory skill training (e.g., goal setting, self-monitoring, relapse
prevention training)
• Ongoing feedback and social support (e.g., peers and loved ones)
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• Guidance from a trained interventionist (e.g., health coach)
REALITY ON THE GROUND
Theoretical progress always runs the risk of not being as effective in real-world
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settings as it is in a controlled laboratory. Health Promotion Advocates, one
of the nation’s leading health promotion advocacy groups, suggests that the
reality on the ground of applied behavior change reflects a stage of craft-logic
with standards of practice not accepted across application settings and
sophisticated research not occurring with enough real-world contextual
diversity:
“
[We] do not understand the interaction of genetics, social norms,
personal choice and environmental factors on the health behaviors
people practice. We do not fully understand what motivates people
to attempt or maintain a lifestyle change… We do not know the
optimal combination of education, skill building, supportive
environments, public policy and other factors in stimulating and
sustaining behavior change… We do not fully understand how to
best adapt strategies to reach different age groups, genders, racial
and ethnic groups or the most important elements for programs in
workplace, home, clinical, school, or community settings… We
have not yet determined which strategies will be most cost
effective with the various population groups we seek to reach…
Unlike more established fields such as medicine or engineering,
there are no stable mechanisms to synthesize health promotion
research into principles that can be applied in practice, or to
disseminate these findings to those who can use them. As such it
takes years for research findings to influence educational
curriculum or to improve the strategies used in practice. This also
creates a huge gap between discoveries that have already been
made and the techniques used in practice, and between the quality
9
of the best programs and the typical programs.
We believe this will continue to be the case until behavior is recognized as the
complex adaptive system that it is. Since behavior is a complex adaptive
system, the only way of dealing with behavior change effectively is through an
equally adaptive paradigm of behavior change support.
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Behavior is a Complex Adaptive System
The theory and methods in the behavior change field still suffer primarily
from lack of a practical paradigm capable of meeting the complexity of
the problem on its own terms.
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WE ARE NOT MACHINES
There are a large number of factors bearing on any given pattern of behaviors
by a single individual in a given context: biological, historical, semantic,
neurological, psychological, economic, legal, sociological, nutritional, medical,
social, spiritual and dozens of others, all interacting with each other in complex
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ways. The hard problem of behavior change support derives from the fact
that behavior itself is a “complex adaptive system,” a term from complexity
28 29 30
theory that describes systems with four characteristics: , ,
1. Entangled: massively interdependent components interact and influence
each other. The factors driving our lifestyles and behavior are massively
entangled (e.g., self-efficacy impacts motivation, which impacts
nutrition, which impacts stress, which impacts sleep, which impacts
work and so on).
2. Dynamic: People are in a constant process of growth and change, from
our priorities and skills to our attention and readiness to take on change
(e.g., Transtheoretical/Stages of Change Model).
3. Emergent: interactions among the parts create novel outcomes.
Individual behavior is influenced by that of peers and environmental
factors and small events can produce unpredictable outcomes (e.g.,
Twitter driving a wide scale uprising in the Middle East).
4. Adapting: people are constantly adapting to new information and
feedback, changing their behavior in relation to social norms, internal
and external rewards, organizational policies etc.
These four features characterize human behavior as a nonlinear, interactive
process in a constant state of continuous and discontinuous change with
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unpredictable outcomes. In short, we are not machines, and our models and
methods have to adapt to this fact if we are going to have any hope of
meeting the complexity of the healthcare crisis on even footing. Many fields
have moved beyond traditional “machine” metaphors and now employ
“organic ecosystem” metaphors to increase the insight and effectiveness of
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their theories and methods. Is it time for healthcare to do so, too?
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Behavior Change Support Needs an Adaptive Paradigm
To change behavior across large-scale populations, the sophistication of
change support will have to become as adaptive as the problem itself.
An adaptive paradigm enables learning and real-time experimentation
that allows us to continually close the gap between our understanding of
behavior in a theoretical way and the outcomes we’re achieving in
diverse and complex real world settings. A central goal is to achieve
mass personalization in a theory-agnostic environment of research,
innovation and cross-disciplinary learning.
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BEHAVIOR CHANGE SUPPORT IS AN ADAPTIVE PROBLEM
If human behavior is an adaptive system, then behavior change support
becomes an adaptive problem. One of our colleagues, Harvard leadership
theorist Ronald Heifetz, describes complex “adaptive problems” as those that
cannot be pinned down to a static set of causes, and to solve them requires a
process of learning and real-time experimentation that allows us to continually
close the gap between our understanding and our actions within a complex
and shifting reality. He contrasts adaptive problems with “technical problems,”
which have solutions that can be identified and engineered once the problem
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is adequately understood. Replacing a crown on a tooth is a technical
challenge, but helping an obese patient lower her BMI is an adaptive one.
To become adaptive, behavior change support will have to discover and adjust
to a wide array of little-understood and even currently unknown variables that
impact on a given change, for a given individual, in a given context, on a given
day, over time, all at a cost that can be borne by funders.
The National Academy of Sciences summarized the challenge this way:
“
Prevention is thus a formidable challenge of wide scope,
influenced not just by virus, gene, and physiological processes but
also by individuals’ cognitions, emotions, and behaviors, all of
which exist within particular environmental, interpersonal,
economic, and cultural contexts. Clearly, advancing the science of
primary prevention is a multidisciplinary task. The committee
recommends that NIH usher in a new era of prevention research,
spanning all institutes and targeted at a refined understanding of
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these complex connections.
COMPLEX ADAPTIVE SYSTEMS HAVE NO SOLUTION
By their nature, complex adaptive systems are in a constant state of flux. In
the case of human behavior, we are in an ongoing process of adaptation to
our physiological, psychological, spiritual and social needs and we do so by
behaving in such a way that we meet our needs as best as we can given a
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certain environment. We are in a constant process of change in order to
achieve temporary states of equilibrium between self and environment.
Behavior is a constantly changing force of adaptation.
Solutions to complex
behavioral problems have
no “solution.” The solution
only emerges by
operationalizing iterative
learning.
Health behavior experts, who design change support programs and
interventions, therefore face a complex, multifaceted task when trying to
drive down the cost and improve the efficacy and outcomes of health
change support. Behavior change support won’t have one “solution,” and
as some experts note will resist theoretical summarization. It is not a
normal “puzzle,” to use Thomas Kuhn’s classic feature of scientific
paradigms, in the manner of which single theories can account. It
operates beyond single theories in our ability to fully account for it
because it is context dependent.
Solutions to complex behavioral problems, therefore, can only be
operationalized, never conclusively solved. The solution to a complex adaptive
problem is not a theory but a process: specifically, implementation of an
ongoing methodological process of continually narrowing differences between
reality and our interventions to change that reality (or in this case, behavior).
This kind of solution is ever-ongoing, process-oriented, dynamic, non-linear
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and trans-theoretical.
THEORY IS DEAD, LONG LIVE THEORY!
This new framing doesn’t diminish the role of theory. If anything, it liberates it.
First by changing the expectation that there is such a thing as a grand theory
of change; perhaps there never will be. However, there have been and will be
dozens of powerful puzzles to be solved in ever more precise contexts. “Why
did that message, framed in that way, work to change eating habits in Austin
in summer but not Minnesota in winter for 25 year old women? What is the
deep structure, if any, of that lesson which might apply to other contexts?”
This liberates theory by narrowing it to a specific kind of puzzle, and then
celebrating its boundary disclaimers rather than looking at them as theoretical
setbacks. It also liberates theory by placing it within an iterative evolutionary
paradigm of refinement, allowing for faster theoretical testing and
experimentation. Because every context represents its own theoretical
landscape, it should be expected that more theoretical constructs will pop up
to account for the true diversity of the landscape. And ultimately every theory
will only catalyze our efforts to get smarter by learning faster.
Conclusions
THE REQUIREMENTS OF A 21ST CENTURY BEHAVIOR CHANGE PARADIGM
After covering a lot of ground, we can now conclude the broad requirements
of such an new adaptive behavior change support paradigm. These
requirements are becoming clear to experts who we work with – several of
which, like the Department of Defense and the National Academy of Sciences,
have been profiled throughout this white paper – and focus centrally on
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achieving mass personalization in an always-on, real-time environment of
research, innovation and cross-disciplinary learning. We also recognize that
this paradigm operates in and among a vast set of interdependent
stakeholders with varying strategic and financial motivations, and that this
paradigm must become adopted on terms that accelerate the creation of
economic and well-being value for each key stakeholder – participants,
families, friends, researchers, health plans, employers, governments, expert
supporters and providers.
1. Continuous, Always-On Support:
a.
Ubiquitous: Pervasive support ecosystem designed around
36, 39
widely deployed mobile technology
b. Continuous Support: Provides low-cost ongoing support for
the long-term maintenance phase of behavior change to
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achieve high participant satisfaction
2. Collaborative Real-Time, Real-World Research:
a.
Community of Learning: Enables a truly high rate of
learning amongst a diverse community of multidisciplinary
27, 38
experts
b. Theory-Agnostic: Supports rapid research and design
modification for testing and evolution in real-time of any
34, 27
change theory
3. Personalized Uniquely to Participants:
a.
Mass Personalized: Change support is tailored uniquely to
each change participant even across large populations
b. Real-Time: Provides real-time emotional and behavioral
support across life conditions and social contexts
c.
Intrinsically Motivated: Change support starts from where
the participant is, from any topic of engagement the
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participant is motivated enough to attempt.
4. Adaptive, Whole Life Support:
a.
Comprehensive: Accounts for a whole spectrum of physical,
emotional, social, nutritional, psychological, spiritual and
1, 34, 39, 40
environmental factors.
b. Multi-Behavioral: Supports seamless multiple behavior
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change interventions with on-the-fly needs detection
c.
Socially Cohesive: Places the participant at the center of a
caring social circle of peers, expert supporters, family and
loved ones.
5. Strategic:
a.
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Financially Rewarding: Produces low cost, high ROI for
payers – insurers, employers, government and self-insured
consumers
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b. Multi-level Integration: The change support ecosystem can
integrate with all levels of an overall change strategy, including
small groups, organizations and population-wide interventions
c.
Lowers Support Costs: Uses cost-free social support from
caring personal relationships, combined in a leveraged way
with expert supporters, to lower the cost of supporting
successful change
d. Drives Loyalty: Drives deeper loyalty to employers, health
plans and health providers that enable lifelong support for
leading healthy, full and productive lives amongst the entire
family
In closing, the problem of chronic conditions and long-term cost trajectories
calls for a base of the pyramid approach to behavior change that is agile,
caring, personalized, innovative and highly-adaptive. We have to enable a new
paradigm of helping people to change behavior, at scale, across diverse
populations so that we achieve real and lasting outcomes in health, well-being
and productivity. As a society, this is just no longer optional.
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Endnotes
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1
Jonas, W., O’Connor, F., et al. Why Total Force Fitness? Military Medicine, 2010; 175(8):6-13
2
World Health Organization (WHO). Preventing Chronic Diseases: A Vital Investment. Geneva:
WHO, 2005.
3
Flegal, K., Carroll, M., Ogden, C. and L. Curtin. Prevalence and Trends in Obesity Among US
Adults, 1999-2008. JAMA. 2010;303(3):235-241
4
National Sleep Foundation. 2005 “Sleep in America” Poll. Washington: National Sleep
Foundation; 2001.
5
Gangwisch JE, Malaspina D, Boden-Albala B et al. Inadequate sleep as a risk factor for obesity:
analyses of the NHANES I. SLEEP 2005; 28(10):1289-1296
6
Stein, C. and G. Colditz. The Epidemic of Obesity. The Journal of Clinical Endocrinology &
Metabolism. 2004;89(6):2522-2525
7
National Center for Health Statistics. “Health, United States, 2007. With Chartbook on Trends in
the Health of Americans.” Hyattsville, MD: 2007
8
McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:22072212.
9
Health Promotion Advocates. “Congressional Briefing Document.”
http://healthpromotionadvocates.org
10
Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: final data for 2005. National Vital Statistics
Reports 2008. 56(10).
11
Wu SY, Green A. “Projection of chronic illness prevalence and cost inflation.” Santa Monica, CA:
RAND Health; 2000.
12
American Psychological Association. 2010 “Stress in America” Report Findings. Washington:
APA; 2010.
13
Center for Medicare and Medicaid Studies. “National Health Expenditure Projections 20092019.” Washington; 2009.
14
Thorpe KE, Howard DH. The Rise In Spending Among Medicare Beneficiaries: The Role Of
Chronic Disease Prevalence And Changes In Treatment Intensity. Health Affairs.
2006;25(5):378-388.
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Finkelstein, E.A., Trogdon, J.G., Cohen, J., and W. Dietz. Annual Medical Spending Attributable
To Obesity: Payer-And Service-Specific Estimates. Health Affairs 28, no. 5 (2009)
16
Center for Disease Control. “Smoking-Attributable Mortality, Years of Potential Life Lost, and
Productivity Losses – United States, 2000—2004.” CDC. Washington, November 14,
2008.
17
Pratt M, Macera CA, Wang G. Higher Direct Medical Costs Associated With Physical Inactivity.
The Physician and Sports Medicine 2000;28(10):63-70.
18
Center for Disease Control. “2011 National Diabetes Fact Sheet.” CDC. Atlanta, Georgia.
19
American Heart Association. http://www.americanheart.org/
20
Rosch, P. J. (Ed.). The quandary of job stress compensation. Health and Stress, 3, 1-4. 2001,
March.
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Goetzel R Z; Anderson D R, et al. The relationship between modifiable health risks and health
care expenditures. An analysis of the multi-employer HERO health risk and cost database.
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Kaplan, R. Two Pathways to Prevention. American Psychologist. 2000;55(4):382-396.
23
Towers Watson. “Purchasing Value in Health Care.” 2010.
24
Glanz, K., Rimer, B. and M.L. Frances. Health Behavior and Health Education, 3rd Ed. JosseyBass. San Francisco, CA. 2002.
25
Kegan, R., Lahey, L. Immunity to Change. Harvard Business School Publishing. Cambridge,
Mass. 2009.
26
Theory at a Glance: A Guide for Health Promotion Practice. National Institutes of Health. 2005.
27
Rothman, A. “Is there nothing more practical than a good theory?": Why innovations and
advances in health behavior change will arise if interventions are used to test and refine
theory. International Journal of Behavioral Nutrition and Physical Activity. 2004;1:11.
28
Marion, R. and Bacon, J. Organizational Extinction and Complex Systems. Emergence.
2000;1(4):71-96.
29
Waldrop, M. Complexity. Touchstone. New York, NY. 1992.
30
Walker, B. and D. Salt. Resilience Thinking. Island Press. Washington, DC. 2006.
31
“Applying Complexity Science to Health and Healthcare.” Center for the Study of Healthcare
Management. University of Minnesota.
32
Begun, J., Zimmerman, B., and Dooley, K. Health Care Organizations as Complex Adaptive
Systems. Published in Mick, S., and Wyttenbach, M. (eds.) Advances in Health Care
Organization Theory. San Francisco, CA. Jossey-Bass. 2003.
33
Heifetz, R. Leadership Without Easy Answers. Cambridge, Mass. Harvard University Press.
1995.
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“New Horizons in Health.” National Academy of Sciences. 2001. Washington, D.C.
35
Kuhn, T. The Structure of Scientific Revolutions. University of Chicago Press. 1962.
36
Oinas-Kukkonen, H. Behavior Change Support Systems: The Next Frontier for Web Science. In:
Proceedings of the Web Science Conf.10: Extending the Frontiers of Society On-Line,
April 26-27th, 2010, Raleigh, NC.
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Rothman, A. Toward a Theory-Based Analysis of Behavioral Maintenance. Health Psychology.
2000;19(S):64-69.
38
Jordan, P., Ory, M., and T. Goldman. Yours, Mine, and Ours: The Importance of Scientific
Collaboration in Advancing the Field of Behavior Change Research. Annals of Behavioral
Medicine. 2005;29(2):7-10.
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B. Arnrich, O. Mayora, J. Bardram and G. Tröster. Pervasive healthcare: paving the way for a
pervasive, user-centered and preventive healthcare model. Methods of Information in
Medicine, 2010; 49(1):67-73.
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Jonas, W. and R. Chez. Toward Optimal Healing Environments in Health Care. J. of Alt. and
Comp. Med. 2004;10(s1):1-6.
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Ory, M., Jordan, P., and T. Bazzarre. The Behavior Change Consortium: setting the stage for a
new century of health behavior-change research Health Education Research. 2002;17(5)
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About Chrysallis
Chrysallis is a human development company whose mission is to
empower people to lead healthy, full, and productive lives by supporting
any change, anywhere, for life. We aim to help the world’s leading
institutions dramatically lower costs through the world’s first platform for
design and distribution of human development, health and well-being
programs. Chrysallis intends to make change easy, successful and
inexpensive through our patented platform for Human Change DesignTM,
which is mobile, social and adapts its support in real-time across diverse
populations. We aim to provide the world’s leading institutions with the
thought leadership, programs and tools necessary to deploy this new,
cost-effective paradigm of lifelong health and well-being to millions of
people.
Chrysallis, Inc.
Reno, Nevada
Menlo Park, California
Auckland, New Zealand
[email protected]
www.millionhelpabillion.com
All Rights Reserved
Copyright © 2011
16
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The Case for a 21st Century Behavior Change Paradigm
April, 2011
By Robb Smith
Chief Executive Officer
Facing the Healthcare Crisis
Chrysallis, Inc.
Introduction
Healthcare is in a crisis because a majority of healthcare spending and
healthcare inflation is driven by chronic conditions caused by unhealthy
lifestyles. It will remain so until a paradigm of mass personalized
behavior change is adopted that can solve the “complex adaptive
problem” of human change. Successful long-term human change
requires an equally adaptive support paradigm that enables learning and
real-time experimentation to continually close the gap between our
understanding of behavior in a theoretical way and the outcomes we’re
achieving in diverse and complex real world settings.
________________________
THE MODERN HEALTHCARE SYSTEM IS UNDER ASSAULT
It is expected to care for, repair and then pay for the massive damage being
inflicted by unhealthy individual behavior of every kind, in every setting, for
every individual. Employers, insurers and taxpayers – the three primary payer
groups – will continue to get crushed by a set of health conditions with
overwhelming cost trajectories, estimated to grow in the U.S. to $4.5 trillion
and nearly 20% of U.S. GDP by 2019. Nearly 80% of the overall spending and
inflation is accounted for by a handful of chronic conditions such as heart
disease, cancer, and diabetes driven in turn by a handful of lifestyle factors –
such as obesity, smoking, inactivity, and stress. And yet, despite
overwhelming evidence of significant ROI from preventive health and wellness
support, prevention continues to be criticized by funders because it is
ineffective at changing peoples’ daily behavior.
CALL FOR A NEW PARADIGM
To say the current global healthcare paradigm is not up to the task before it is
an understatement: trying to address the totality of a massively complex
biological, psychological, social, economic, and behavioral dynamic with an
acute care model at the tip of the spear, a chronic care model in the middle
and a one-size-fits-all preventive care model at the base of the pyramid will not
work. The U.S. Department of Defense, with their recently articulated principle
of “total force fitness,” is at the forefront of defining what a new paradigm will
need:
Achieving total force fitness involves … a system that addresses
an integrated whole person, including family, social, physical and
spiritual aspects … used in an integrated fashion for continual
process improvements… Such evaluations will also require a new
paradigm of research that uses information systems for rapidly
tracking components of total force fitness… Such an integrated
paradigm includes contextual understanding of person-specific
variables, uses innovative approaches based on rigorous methods
of empirical evaluation, and should narrow the gap between
science, health care, and training. We cannot sustain our force by
1
staying within the present paradigm.
They are not alone. Other experts are also calling for ubiquitous, personalized
1
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and integrative preventive health that places the patient at the center of care
and accounts for a whole spectrum of physical, emotional, social, nutritional,
psychological, spiritual and environmental factors. At the heart of this
integrated, primary preventive health model is a requirement to achieve
sustainable behavior change across large-scale, heterogeneous populations at
a cost that is affordable to payers – a "holy grail" that has yet to be achieved.
Based on extensive research integrated from a wide variety of disciplines, we
believe that a pervasive, adaptive and mass personalized behavior change
ecosystem is necessary to change healthcare cost and outcome trajectories.
The behavior change support paradigm we call for will require a
comprehensive “whole-person, whole-system” view that meets these
requirements:
1. Everywhere and Always-On Support
2. Collaborative Real-Time, Real-World Research
3. Mass Personalized to Each Participant
4. Contextually-Adaptive, Whole Life Support
5. Strategic ROI for Payers
Anything that falls short of changing the behaviors of millions of people,
behaviors that are creating the chronic conditions in the first place, will not fully
alleviate the human suffering, the cost waste, and the loss of economic and
energetic productivity from a majority of our population. Even if we make
progress through new payer structures, by moving to greater care
management, achieving better chronic management modalities, cost-shifting
to consumers, or any other structural change in the current paradigm, they are
merely workarounds. The base of the pyramid problem will remain: we have to
enable a new paradigm of helping people to change behavior, at-scale, across
diverse populations so that we achieve real and lasting outcomes in health,
well-being and productivity.
2
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Our Lifestyles Are Killing Us
Unless and until we find a way to attack the healthcare problem costeffectively at the very base of the pyramid – the World Health
Organization estimates that 80% of heart disease, stroke, type 2
diabetes and 40% of cancer would be prevented through better diets,
more exercise and not smoking2 – costs and poor health trajectories
from the current paradigm of acute care and chronic care management
will continue to grow unabated.
________________________
DAILY BEHAVIOR IS THE BASE OF THE HEALTHCARE PYRAMID
Healthcare concerns the ongoing functioning of the body, and what we eat,
what we feel, how much stress we’re under, how much exercise we get, and
how much sleep we get are among the basic building blocks of a healthy
lifestyle. And on each of these measures the population trajectories are getting
worse.
Rates of obesity have been rising for the past 30 years, and though they may
be beginning to stabilize, as of 2008 68% of adults in the US are
overweight (BMI>25) and half of those, or nearly 34% of the adult
3
population, are clinically obese (BMI>30). We’re getting less sleep
By 2020 almost half of the
than we used to, with Americans who report sleeping eight or more
entire population of the
hours a night on weekdays declining from 38% in 2001 to 26% in
4
United States will have at
2005; lack of sleep is indicated as a causative factor in obesity due
least one chronic condition.
to changes in appetite regulation, food cravings, increased bodymass index, decreased glucose tolerance, and increased insulin
5
resistance. Our daily net energy balance also seems to have
gotten worse with higher per capita caloric availability, increased
consumption of fast foods and soft drinks, larger portion sizes, and more time
spent watching television. Fully 60% of the U.S. population does not engage in
6
regular physical activity and 25% are completely sedentary. On top of all this,
more than 43 million Americans smoke cigarettes, which alongside obesity is
7
one of the top drivers of chronic healthcare costs.
Approximately 40% of all deaths in the United States are premature due to
8
unhealthy lifestyle choices (smoking, diet, alcohol and drugs) and unhealthy
lifestyle is the primary contributor to heart disease, cancer, stroke, respiratory
disease, and diabetes, which collectively account for 70% of all deaths (e.g.,
9 10
more than 1.7 million people in 2005). , More than 125 million Americans had
at least one chronic condition in 2000, which is expected to grow to 157
11
million Americans by 2020. By 2020 almost half of the entire population of
the United States will have at least one chronic condition.
WE’RE STRESSED OUT
The American Psychological Association reports that money and work
concerns account for very significant stress in 76% of adults in 2010, and that
while 69% place a priority on managing stress only 32% believe they are doing
a very good job of managing it. Adults place a high priority on several aspects
of overall well-being, including getting enough sleep (62%), eating healthy
3
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(64%) and being physically active (60%), but in each case only a fraction
believe they are effective in doing so (25%, 30%, and 29% respectively).
Adults cite a lack of willpower (29%) as the most common reason for not
adopting healthier lifestyle changes. Making matters worse, in 2010 almost
40% of adults report that they manage their stress levels by watching more
12
than 2 hours of television every day.
OUR LIFESTYLE BEHAVIORS ARE MULTIFACETED AND DYNAMIC
What is clear is that our lifestyles, health outcomes and behaviors are not
single variable systems but instead constitute a complex adaptive system
(e.g., physiology and behavior impact health, our health impacts work
performance and stress levels, our stress impacts behavior and sleep, and so
on the cycle goes). With the complexity inherent in changing health behaviors,
where each factor potentially bears on all others, it is not surprising that longterm trajectories are bad and getting worse.
Healthcare Cost Trajectories are Shockingly Bad
Chronic conditions caused primarily by poor lifestyle and behavior
choices account for a majority of overall healthcare inflation, a majority
of overall healthcare spending, and hundreds of billions of dollars
annually in additional indirect costs to individuals, employers, taxpayers
and society.
________________________
CONFRONTING THE FULL COST OF OUR LIFESTYLES
Unhealthy behaviors alone
may add another $1.33
trillion in annual healthcare
spending by 2019.
Total U.S. healthcare spending is expected to grow from $2.5 trillion in
2009, or 17.3% of GDP, to $4.5 trillion by 2019, or 19.3% of GDP.
Updated estimates from the Center for Medicare & Medicaid Services
project annual growth in healthcare spending from 2010 to 2019 at 6.3%
13
per annum, and if recent history is a guide, then most of this increase, or
14
66%, will be attributable to unhealthy behaviors, and in particular obesity.
Chronic conditions alone accounted for 78% of all healthcare spending in
11
1998, which if projected forward in constant terms translates into $1.95
trillion in 2009. The major chronic conditions and their causative lifestyle
behaviors represent a devastating toll in human suffering and drag on U.S.
national annual economic output:
15
• Obesity accounts for $147 billion in direct medical costs annually, not
counting indirect costs for absenteeism, lost productivity or other costs
borne by employers.
• Smoking accounts for $193 billion in direct medical costs and lost
16
productivity annually.
17
• Physical inactivity accounts for $201 billion in direct medical costs.
18
• Diabetes accounts for $218 billion in total costs in 2007, and as much
4
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as 80% of type 2 diabetes might be attributed to inactivity and
6
overweight/obesity.
• Cardiovascular diseases, including heart disease and stroke, account for
19
a staggering $480 billion in direct medical costs and indirect costs.
• Work-related stress is estimated to cost U.S. employers more than $300
20
billion annually on absenteeism, lost productivity and health claims, and
employees who are feeling high stress have 46% higher total healthcare
21
expenditures than those who don’t.
• Mood disorders are estimated to cost more than $50 billion in lost
productivity.
The implications of the current healthcare cost and lifestyle data is clear:
chronic conditions caused primarily by poor lifestyle and behavior choices
account for a majority of overall healthcare inflation, a majority of overall
healthcare spending, and hundreds of billions of dollars annually in additional
indirect costs to individuals, employers, taxpayers and society.
AND THE SITUATION IS POISED TO GET WORSE
With the passage of the Patient Protection and Affordable Care Act (i.e.,
“Obamacare”) the current healthcare paradigm is heading for trouble, with 35
million or more new patients coming on to insurance rolls in the next 5 years
with no material change in the underlying supply of medical care. We are
heading either for even more healthcare inflation or care rationing, and perhaps
both, and the current acute care model will likely have to change. Preventive
care will increasingly be on the strategic critical path for both providers and
payers, including employers. Under the accountable care organization models
(ACOs) contained in PPACA, providers will be paid increasingly on efficiency of
care rather than volume of care, which will incentivize efficiency-based
preventive care and a move away from volume-based acute care. On the
payer side, with "medical loss ratios" (MLRs) now capped at 85% for large
insureds, it is clear that a move to preventive care that reduces long-term
direct and indirect costs is also now on the critical path for payers.
The data make an overwhelming case for attacking the lifestyle problem by
moving healthcare resources and attention to health promotion through
primary and secondary prevention. Primary prevention seeks behavior and
lifestyle changes that reduce the likelihood that health problems ever occur in
22
the first place and compares to secondary prevention, which is aimed at
trying to identify the early onset of diseases and then manages their severity
and progression (an effort that became associated with the disease
management industry of the past decade). If the case is so compelling, why
aren’t we doing it?
THE LESSON FROM EMPLOYERS
Sitting on the front line of the healthcare crisis, the lessons from employers are
instructive. A national survey of large employers in the U.S. in 2010 reported
that of eleven possible threats to maintaining affordable health coverage for
their employees, the top-rated threat was employees’ poor health habits, with
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Healthy-lifestyle behavior
change came in dead last
with only 6% of vendors
rated by employers as
highly effective and a full
2/3 of vendors rated as not
at all or only slightly
effective.
67% of employers citing it as the top threat. (The third most prevalent threat
was “underuse of preventive health services.”) And when asked what the top
obstacle to changing employee health-related behaviors, employers cited “lack
of employee engagement” by a margin of nearly 2:1 to the second-rated
23
obstacle (“lack of financial incentives for participation”). The employer
picture is clear: they see that behavior change is the linchpin of rising
healthcare costs, and yet employee engagement is the top obstacle to
serious behavior change efforts. Poor employee engagement is not
surprising: many preventive healthcare efforts treat adults like patients that
need to be cared for rather than engaging them on their own terms, in the
issues that people desperately want to change in their own lives.
Employers are demanding better approaches to behavior change but
aren’t getting it. In the same survey when they were asked to rate the
performance of their healthcare vendors across a spectrum of 8 factors of
success, healthy-lifestyle behavior change came in dead last with only 6%
of vendors rated as highly effective and a full 2/3 of vendors rated as not at
all or only slightly effective. Despite efforts by commercial wellness vendors to
promote their services’ return-on-investment to employers, current
approaches are failing, which is why 83% of companies had recently
revamped or expected to revamp their healthcare strategy in 2010, up from
23
59% in 2009. Employers remain highly skeptical of ROI claims from wellness
companies.
The Hardest Scientific Problem in the World?
Poor behavioral outcomes reflect the complexity of the problem, and
despite decades of research and progress on many theoretical fronts to
understand various components of behavior change, the reality on the
ground suggests we cannot consistently operationalize behavior change
across diverse populations.
________________________
BEHAVIOR CHANGE IS COMPLEX
One social scientist has been quoted as saying that changing health behavior
24
“is one of the most complex tasks yet confronted by science.” Evidence
suggests he may be right: some reports show that 50% of people cannot
sustain even a straightforward prescription course. Remarkably, 6 of 7 people
25
will not change even when lifestyle changes may prevent death. And yet,
despite the daunting statistics, the efforts of behavioral heath scientists and
practitioners over the past several decades have been extraordinary in
illuminating the full scope of the behavior change challenge.
CURRENT MODELS OF BEHAVIOR CHANGE
Behavior change research is a multi-disciplinary affair involving insights and
theoretical contributions from psychology, sociology, economics,
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neuroscience, medicine, marketing, semiotics, philosophy and dozens of other
disciplines. There are not only a huge number of potential variables
interdependently interacting across the life condition of a given participant in a
change process, there are also three different levels of analysis and
intervention: individual factors and processes, social factors and processes,
and population factors and processes. Behavior change theories, by
necessity, reflect individual, intrapersonal behavior (e.g., Health Belief Model,
Theory of Reasoned Action, Transtheoretical model, Precaution Adoption
Process Model etc.), interpersonal dynamics (e.g., Social Cognitive Theory,
social networks, social support etc.) and large community health behaviors
(e.g., Diffusion of Innovations, Media Studies Framework, Communication
26
Theory etc.).
From NIH’s Theory at a Glance (see endnote)
Not surprisingly the field has a diverse and fragmented theoretical foundation:
in the mid-1990s a meta-study revealed that within the 526 academic behavior
change papers reviewed there were 66 different theories and models of
24
behavior change being used. There may be even more today (we argue
below that perhaps this is to be expected).
Despite a large and fragmented landscape of theories – many of which overlap
in significant ways and are complementary to each other – interventions have
41
begun to converge around key areas of focus:
• Change initiation factors (e.g., self-efficacy, expectations of benefits and
costs, preparedness for change)
• Self-regulatory skill training (e.g., goal setting, self-monitoring, relapse
prevention training)
• Ongoing feedback and social support (e.g., peers and loved ones)
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• Guidance from a trained interventionist (e.g., health coach)
REALITY ON THE GROUND
Theoretical progress always runs the risk of not being as effective in real-world
27
settings as it is in a controlled laboratory. Health Promotion Advocates, one
of the nation’s leading health promotion advocacy groups, suggests that the
reality on the ground of applied behavior change reflects a stage of craft-logic
with standards of practice not accepted across application settings and
sophisticated research not occurring with enough real-world contextual
diversity:
“
[We] do not understand the interaction of genetics, social norms,
personal choice and environmental factors on the health behaviors
people practice. We do not fully understand what motivates people
to attempt or maintain a lifestyle change… We do not know the
optimal combination of education, skill building, supportive
environments, public policy and other factors in stimulating and
sustaining behavior change… We do not fully understand how to
best adapt strategies to reach different age groups, genders, racial
and ethnic groups or the most important elements for programs in
workplace, home, clinical, school, or community settings… We
have not yet determined which strategies will be most cost
effective with the various population groups we seek to reach…
Unlike more established fields such as medicine or engineering,
there are no stable mechanisms to synthesize health promotion
research into principles that can be applied in practice, or to
disseminate these findings to those who can use them. As such it
takes years for research findings to influence educational
curriculum or to improve the strategies used in practice. This also
creates a huge gap between discoveries that have already been
made and the techniques used in practice, and between the quality
9
of the best programs and the typical programs.
We believe this will continue to be the case until behavior is recognized as the
complex adaptive system that it is. Since behavior is a complex adaptive
system, the only way of dealing with behavior change effectively is through an
equally adaptive paradigm of behavior change support.
8
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Behavior is a Complex Adaptive System
The theory and methods in the behavior change field still suffer primarily
from lack of a practical paradigm capable of meeting the complexity of
the problem on its own terms.
________________________
WE ARE NOT MACHINES
There are a large number of factors bearing on any given pattern of behaviors
by a single individual in a given context: biological, historical, semantic,
neurological, psychological, economic, legal, sociological, nutritional, medical,
social, spiritual and dozens of others, all interacting with each other in complex
41
ways. The hard problem of behavior change support derives from the fact
that behavior itself is a “complex adaptive system,” a term from complexity
28 29 30
theory that describes systems with four characteristics: , ,
1. Entangled: massively interdependent components interact and influence
each other. The factors driving our lifestyles and behavior are massively
entangled (e.g., self-efficacy impacts motivation, which impacts
nutrition, which impacts stress, which impacts sleep, which impacts
work and so on).
2. Dynamic: People are in a constant process of growth and change, from
our priorities and skills to our attention and readiness to take on change
(e.g., Transtheoretical/Stages of Change Model).
3. Emergent: interactions among the parts create novel outcomes.
Individual behavior is influenced by that of peers and environmental
factors and small events can produce unpredictable outcomes (e.g.,
Twitter driving a wide scale uprising in the Middle East).
4. Adapting: people are constantly adapting to new information and
feedback, changing their behavior in relation to social norms, internal
and external rewards, organizational policies etc.
These four features characterize human behavior as a nonlinear, interactive
process in a constant state of continuous and discontinuous change with
31
unpredictable outcomes. In short, we are not machines, and our models and
methods have to adapt to this fact if we are going to have any hope of
meeting the complexity of the healthcare crisis on even footing. Many fields
have moved beyond traditional “machine” metaphors and now employ
“organic ecosystem” metaphors to increase the insight and effectiveness of
32
their theories and methods. Is it time for healthcare to do so, too?
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Behavior Change Support Needs an Adaptive Paradigm
To change behavior across large-scale populations, the sophistication of
change support will have to become as adaptive as the problem itself.
An adaptive paradigm enables learning and real-time experimentation
that allows us to continually close the gap between our understanding of
behavior in a theoretical way and the outcomes we’re achieving in
diverse and complex real world settings. A central goal is to achieve
mass personalization in a theory-agnostic environment of research,
innovation and cross-disciplinary learning.
________________________
BEHAVIOR CHANGE SUPPORT IS AN ADAPTIVE PROBLEM
If human behavior is an adaptive system, then behavior change support
becomes an adaptive problem. One of our colleagues, Harvard leadership
theorist Ronald Heifetz, describes complex “adaptive problems” as those that
cannot be pinned down to a static set of causes, and to solve them requires a
process of learning and real-time experimentation that allows us to continually
close the gap between our understanding and our actions within a complex
and shifting reality. He contrasts adaptive problems with “technical problems,”
which have solutions that can be identified and engineered once the problem
33
is adequately understood. Replacing a crown on a tooth is a technical
challenge, but helping an obese patient lower her BMI is an adaptive one.
To become adaptive, behavior change support will have to discover and adjust
to a wide array of little-understood and even currently unknown variables that
impact on a given change, for a given individual, in a given context, on a given
day, over time, all at a cost that can be borne by funders.
The National Academy of Sciences summarized the challenge this way:
“
Prevention is thus a formidable challenge of wide scope,
influenced not just by virus, gene, and physiological processes but
also by individuals’ cognitions, emotions, and behaviors, all of
which exist within particular environmental, interpersonal,
economic, and cultural contexts. Clearly, advancing the science of
primary prevention is a multidisciplinary task. The committee
recommends that NIH usher in a new era of prevention research,
spanning all institutes and targeted at a refined understanding of
34
these complex connections.
COMPLEX ADAPTIVE SYSTEMS HAVE NO SOLUTION
By their nature, complex adaptive systems are in a constant state of flux. In
the case of human behavior, we are in an ongoing process of adaptation to
our physiological, psychological, spiritual and social needs and we do so by
behaving in such a way that we meet our needs as best as we can given a
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certain environment. We are in a constant process of change in order to
achieve temporary states of equilibrium between self and environment.
Behavior is a constantly changing force of adaptation.
Solutions to complex
behavioral problems have
no “solution.” The solution
only emerges by
operationalizing iterative
learning.
Health behavior experts, who design change support programs and
interventions, therefore face a complex, multifaceted task when trying to
drive down the cost and improve the efficacy and outcomes of health
change support. Behavior change support won’t have one “solution,” and
as some experts note will resist theoretical summarization. It is not a
normal “puzzle,” to use Thomas Kuhn’s classic feature of scientific
paradigms, in the manner of which single theories can account. It
operates beyond single theories in our ability to fully account for it
because it is context dependent.
Solutions to complex behavioral problems, therefore, can only be
operationalized, never conclusively solved. The solution to a complex adaptive
problem is not a theory but a process: specifically, implementation of an
ongoing methodological process of continually narrowing differences between
reality and our interventions to change that reality (or in this case, behavior).
This kind of solution is ever-ongoing, process-oriented, dynamic, non-linear
35, 41
and trans-theoretical.
THEORY IS DEAD, LONG LIVE THEORY!
This new framing doesn’t diminish the role of theory. If anything, it liberates it.
First by changing the expectation that there is such a thing as a grand theory
of change; perhaps there never will be. However, there have been and will be
dozens of powerful puzzles to be solved in ever more precise contexts. “Why
did that message, framed in that way, work to change eating habits in Austin
in summer but not Minnesota in winter for 25 year old women? What is the
deep structure, if any, of that lesson which might apply to other contexts?”
This liberates theory by narrowing it to a specific kind of puzzle, and then
celebrating its boundary disclaimers rather than looking at them as theoretical
setbacks. It also liberates theory by placing it within an iterative evolutionary
paradigm of refinement, allowing for faster theoretical testing and
experimentation. Because every context represents its own theoretical
landscape, it should be expected that more theoretical constructs will pop up
to account for the true diversity of the landscape. And ultimately every theory
will only catalyze our efforts to get smarter by learning faster.
Conclusions
THE REQUIREMENTS OF A 21ST CENTURY BEHAVIOR CHANGE PARADIGM
After covering a lot of ground, we can now conclude the broad requirements
of such an new adaptive behavior change support paradigm. These
requirements are becoming clear to experts who we work with – several of
which, like the Department of Defense and the National Academy of Sciences,
have been profiled throughout this white paper – and focus centrally on
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achieving mass personalization in an always-on, real-time environment of
research, innovation and cross-disciplinary learning. We also recognize that
this paradigm operates in and among a vast set of interdependent
stakeholders with varying strategic and financial motivations, and that this
paradigm must become adopted on terms that accelerate the creation of
economic and well-being value for each key stakeholder – participants,
families, friends, researchers, health plans, employers, governments, expert
supporters and providers.
1. Continuous, Always-On Support:
a.
Ubiquitous: Pervasive support ecosystem designed around
36, 39
widely deployed mobile technology
b. Continuous Support: Provides low-cost ongoing support for
the long-term maintenance phase of behavior change to
37
achieve high participant satisfaction
2. Collaborative Real-Time, Real-World Research:
a.
Community of Learning: Enables a truly high rate of
learning amongst a diverse community of multidisciplinary
27, 38
experts
b. Theory-Agnostic: Supports rapid research and design
modification for testing and evolution in real-time of any
34, 27
change theory
3. Personalized Uniquely to Participants:
a.
Mass Personalized: Change support is tailored uniquely to
each change participant even across large populations
b. Real-Time: Provides real-time emotional and behavioral
support across life conditions and social contexts
c.
Intrinsically Motivated: Change support starts from where
the participant is, from any topic of engagement the
41
participant is motivated enough to attempt.
4. Adaptive, Whole Life Support:
a.
Comprehensive: Accounts for a whole spectrum of physical,
emotional, social, nutritional, psychological, spiritual and
1, 34, 39, 40
environmental factors.
b. Multi-Behavioral: Supports seamless multiple behavior
41
change interventions with on-the-fly needs detection
c.
Socially Cohesive: Places the participant at the center of a
caring social circle of peers, expert supporters, family and
loved ones.
5. Strategic:
a.
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Financially Rewarding: Produces low cost, high ROI for
payers – insurers, employers, government and self-insured
consumers
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Chrysallis, Inc.
b. Multi-level Integration: The change support ecosystem can
integrate with all levels of an overall change strategy, including
small groups, organizations and population-wide interventions
c.
Lowers Support Costs: Uses cost-free social support from
caring personal relationships, combined in a leveraged way
with expert supporters, to lower the cost of supporting
successful change
d. Drives Loyalty: Drives deeper loyalty to employers, health
plans and health providers that enable lifelong support for
leading healthy, full and productive lives amongst the entire
family
In closing, the problem of chronic conditions and long-term cost trajectories
calls for a base of the pyramid approach to behavior change that is agile,
caring, personalized, innovative and highly-adaptive. We have to enable a new
paradigm of helping people to change behavior, at scale, across diverse
populations so that we achieve real and lasting outcomes in health, well-being
and productivity. As a society, this is just no longer optional.
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Endnotes
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About Chrysallis
Chrysallis is a human development company whose mission is to
empower people to lead healthy, full, and productive lives by supporting
any change, anywhere, for life. We aim to help the world’s leading
institutions dramatically lower costs through the world’s first platform for
design and distribution of human development, health and well-being
programs. Chrysallis intends to make change easy, successful and
inexpensive through our patented platform for Human Change DesignTM,
which is mobile, social and adapts its support in real-time across diverse
populations. We aim to provide the world’s leading institutions with the
thought leadership, programs and tools necessary to deploy this new,
cost-effective paradigm of lifelong health and well-being to millions of
people.
Chrysallis, Inc.
Reno, Nevada
Menlo Park, California
Auckland, New Zealand
[email protected]
www.millionhelpabillion.com
All Rights Reserved
Copyright © 2011
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