Unbiased Estimate

We recently examined how the proliferation of strategies to better manage health risk and contain healthcare costs are driving demand for tech solutions that: 

• help individuals to better manage their health and get more value for their healthcare dollar, and
• help institutions such as health plans, employers and providers to better engage their members, employees and patients to be more engaged in their health and care.

• Consumer: Microsoft Healthvault, Motherknows, Zweena Health
• Institution: Dossia, Kaiser My Health Manager, Aetna PHR, Avado, countless provider sponsored patient portals

• Consumer: Healthcare Bluebook, Angie’s List, Hospital Compare
• Institution: Castlight, Thomson Reuters, Wellpoint Treatment Cost Advisor

• Consumer: Simplee, Cake Health
• Institution: Increasingly part of health plans’ portals

• Consumer: ZocDoc
• Institution: Thousands of online provider appointment scheduling systems

• Consumer: RememberItNow, Vitality Glowcaps, Medminder
• Institution: Health Prize, Proteus Biomedical

• Consumer: RealAge, 23andme, 100Plus
• Institution: BioSignia, Staywell, Mayo Clinic Health Assessment, Navigenix

• Consumer: RunKeeper + Earndit + Bonobos
• Institution: Virgin HealthMiles and numerous home-grown workforce wellness programs

1. Their interests (financial or otherwise) must genuinely be aligned
2. They must provide products that members would be motivated to use, if not pay for, on their own

It can be downright depressing when you consider just how entrenched unhealthful lifestyle behaviors (like physical inactivity and poor diet) have become in American culture, so it is encouraging to recount instances that demonstrate that indeed social norms can and do change dramatically over time, sometimes for the better, and that peer pressure can be just as effective at fostering positive behaviors as negative behaviors. I’ve recently been reminded of three notable examples:

Smoking breaks at the workplace - Decades ago in the US smoking was broadly considered to be socially acceptable, and many individuals would feel peer pressure to join colleagues for smoking breaks on the job. Smoking breaks were a time to socialize and unwind, and an excuse to take a break from work. Unfortunately this is still the case in many vocations (and around 20% of American adults still smoke). However, there are a good number of workplaces where it is now socially unacceptable to smoke, where peer pressure works in the opposite direction, and where (a) smoker is left out in the cold, alone, feeling isolated from peers.

Exercising at the Pentagon - A friend recently recounted his experience as an intern at the Pentagon. He told me that for the first time in his life he started going to an (onsite) fitness center, and when I asked him why his response surprised me. He said that everybody he worked with, despite being incredibly busy, brought a gym bag to work and at some point during each day they would disappear to fit in a workout. He said he felt “judged” for not doing so himself, so he began to follow suit, and ended up getting fitter than he had ever been over the course of his internship. I have to assume that this norm has not always been present at the Pentagon, and is not ubiquitous across divisions, but rather was something that evolved among the group of people with whom my friend was working.

Beat the Peak - A recent Atlantic article highlighted how in Tucson, the social acceptability of maintaining a green lawn (which in the desert requires a lot of water, a limited resource) has, over time, become taboo. This was not always the case, but thanks in part to a decades old initiative called ‘Beat the Peak’ the social norm has evolved such that Tucsonians now frown upon green lawns, and residents feel peer pressure to ‘pass on grass’ - as their perceived misdeeds are evident to all their neighbors. There are some good quotes throughout this article about the social psychology underpinning the city’s efforts, and how city officials have borrowed heavily from marketing techniques used to influence consumer behavior. (Disclosure: I have never been to Tucson, and cannot attest to whether this article overstated the phenomenon)

These are obviously just a few instances where social norms evolve over time among groups of people to eventually exert peer pressure toward a positive or healthful behavior, and there are undoubtedly many more to speak of.

Just as, in terms of individual behavior change, the aim to get to the place where the individual is intrinsically motivated to pursue a healthful behavior that has also become routine, when thinking about social behavior change, the aim to get to the place where a healthful behavior becomes both the social norm as well as the default pathway.

These changes do not happen overnight, nor do they happen by accident. Depending on the behavior, misinformation and bias may need to be overcome, policies and even physical environments may need to change, and ‘early adopters’ may need to create visibility around a new way of doing things. However it is instructive to note that they can indeed change, and to learn from past successes to inform ongoing efforts to change social norms.

It’s that time of year again when millions of American employees go through the annual benefit enrollment process. As highlighted in a recent WSJ article, employees will once again be asked to contribute a greater share toward their health benefits in 2012.

Why? The cost of healthcare (and thus health insurance) keeps going up, and employers, faced with year over year healthcare cost increases that far outpace the rate of inflation, have been - and continue to - shift costs to their employees. There are a lot of ways to do so (e.g., increased premiums, co-pays and co-insurance) but high-deductible health plans are emerging as a primary method of shifting cost, risk and responsibility to employees. Today an estimated 17% of US employees are enrolled in high deductible plans, and this number is rising quickly.

For many of those unaccustomed to managing financial risk related to health, this trend is likely to be perceived with strong negative valence.

Though perhaps painful in the short run, I believe that shifting healthcare costs to employees (and patients in general) is a positive trend for several reasons.

First, rising healthcare costs have been responsible for stagnant wage growth, attenuated job growth, a mix of higher taxes and public debt (mostly the latter), and higher prices on domestic goods. All of these cause financial harm to employees. Up until now employers have, on the surface, absorbed healthcare cost inflation, and they have clearly suffered for doing so in terms of global competitiveness. But the brunt of the pain has not been directed at corporate profits, but rather employee salaries. Employees have been getting screwed by high healthcare costs for decades, mostly without realizing it. Now at least they are starting to wake up to reality, starting to demand change. I think that’s a good thing. OWS take notice.

So what if costs are too high (thanks Captain Obvious!) - how does giving employees a high deductible help?

The way I see it, though there are two general strategies that could purportedly contain healthcare spending, there is only one that could, in reality, be successfully implemented in the US.

The first strategy would involve implementing a single-payer healthcare system wherein the prices and scope of services available are determined by government panels, and cost targets are met by rationing care when necessary. As a strong proponent of public health promotion I find this approach to be very attractive in so far as a single healthcare payer has a strong financial incentive to invest in long-term population health (mmmm, nanny state!) . However, this approach has so far fallen outside of the historic American social contract, rather achieving acceptance in smaller, more homogenous nations or those with a distinct social-political climate (where, though costs are lower than in the US, cost containment is still a struggle) . Moreover, it is my belief that the US federal government, due to strong influences from industry and other special interests, would be incapable of granting decision making bodies sufficient authority to make the hard (life and death), objective (utilitarian) decisions necessary to effectively control costs. If you disagree, that’s great, and I’d love to hear from you.

The second strategy relies less on the question of who pays for healthcare, but rather on the question of how they pay for it, and flows from the axiom that health insurance (as well as employee health benefits) in the US have over the last several decades become completely irrational. Insurance is a financial instrument reserved to cover the costs of incidences that are “random, infrequent and catastrophic”. Paying for routine care with health insurance is incredibly inefficient, and has often been compared to paying for an oil change and tire rotation with auto-insurance. Nonsensical right?

Thus a critical component to achieving a more rational, high-value healthcare system is the advancement of consumerism. For some time insured patients have been almost completely obscured to the true costs of their care, and have had little access to information about the comparative quality and value of providers and services. As result, patients have not been treated like consumers, and have wielded little power to demand high value care. Many individuals now responsible for the first several thousand dollars of their care, are, either out of necessity or principle, starting to ask the hard questions about the value of their care. Few stakeholders are ready with answers, but that is changing (more on that in my next post).  

For those of you who might argue that, because healthcare is a special and necessary commodity that does not follow traditional laws of supply and demand, it cannot be viewed through a standard economic lens, I concede that in a good number of instances (such as a medical emergency) it is not reasonable to ask a patient to make a value conscious decision (and I am in no way saying consumerism is a silver bullet, it is one component of a multi-tiered payment system that is optimized around value). However I counter that in many other cases (like routine care) it would be advantageous to do so. Moreover, I would remind you that healthcare in the US is a $2.7T (T stands for “trillion”) industry that threatens to cripple the most powerful nation on the planet with debt. I don’t think we can afford to treat it as a sacred cow. I’d also add that consumerism does not mean that care cannot be subsidized for those who cannot afford it, but again the manner in which the money is allocated would change.

The most well-articulated portrayal of moral hazard in our current system, and subsequent argument for the ‘radical’ consumerization of healthcare that I have read was written by David Goldhill and appeared in the Atlantic in 2009 - I would highly recommend reading it.

In short, as patients begin to pay the bills for more and more of their (non catastrophic) care, they will demand value for their hard-earned money, forcing the healthcare system to re-orient itself to provide consumer-friendly, convenient, cost-conscious care.

A recent study by RAND showed that employees on high-deductible health plans incur substantially lower costs than those in traditional insurance models, but the same study also observed that these same individuals forgo both unnecessary as well as preventive care. That last bit is a real problem. If individuals on high-deductible plans skimp on high-value, preventive care, that is likely to be bad for both their long terms health, as well as their long-term healthcare costs.

That’s where a concept called Value Based Benefit Design, which came out of UMich almost ten years ago, comes into play. Think of this as an attempt to further rationalize health spending by removing financial barriers to patients getting high value care. Wellness visits, vaccinations, screenings, high value medications, etc - all ‘free’ to the member - or financially incentivized. Financial incentives for participation in health promotion programs and meeting health behavior and biometric cutoffs is a natural extension of this model that is being applied by more and more employers and health plans. The recent health bill (PPACA) drew heavily from the value-based benefit design, making free preventive care a mandatory component of all authorized health plans, and increasing the the financial carrots and sticks that employers are allowed to offer to employees to encourage wellness engagement.

As result of the advancement of consumerism in healthcare, as well as the layering of value-based benefit design elements, we are seeing patients - now increasingly becoming consumers in a market ill equipped to treat them as such - clamoring for tools and solutions to help them be more discerning consumers, more engaged health citizens - which historically have not been in demand, and are therefore only now becoming available.

At the same time, as stakeholders that are responsible for managing risk with regard to healthcare cost inflation (health plans, self-insured employers, and now perhaps providers (e.g., ACOs)) attempt to pay for (or provide) higher value care, we’re beginning to see them clamor for tools to help them do so…as well as solutions to help them engage their members/patients/employees to be more proactive participants in their health and care.

These tools and solutions, nested in the context of everything described above, are a main focus of this blog. In the next couple posts we’ll begin to dive into this newly created demand from patients, payers and providers, as well as the solutions emerging to meet it.

Atul Gwande has famously described a major problem of modern medicine: too often medical professionals fail to consistently implement known best practices. He has used the not-infrequent failure of doctors to wash their own hands as a prime example, however concedes that this is a widespread problem, as evidenced by myriad inconsistencies in care delivery that cause substantial, avoidable suffering and death.

Gwande describes a growing gulf between what is known to be best practice in medicine and the reality of what medical professionals do on a daily basis.

I see a parallel, but even more dramatic gulf between what is known about the lifestyle behaviors that are necessary to promote health, and the typical modern/American lifestyle.

Over the last half-century we have witnessed an explosion of scientific knowledge - from the fields of medicine, physiology, biochemistry and particularly epidemiology - such that we now have far better grasp than ever regarding the kinds of lifestyle behaviors that lead to favorable health outcomes, and the kind that cause premature disease and death. For example, we now have a dramatically better understanding of the effects of tobacco use, physical activity, diet/nutrition, sleep and other health-related behaviors. Enough so that if everybody did what we already know to be good for them, we could prevent over 90% of type II diabetes, 80% of heart disease and 40% of cancer. Achieving these results would arguably be the most important health breakthrough in the history if the world.

So as scientists have forged ahead with new discoveries and established a clear paradigm for optimal health behaviors, in doing so they have created a giant gulf between knowledge and practice.

Why does this gulf persist?

First, it’s inevitable that there will be a time lag between new discoveries and the broad deployment of corresponding interventions and other changes that require the gradual attainment of new awareness and mobilization to action across large populations.

Second, the behaviors in which these (relatively) new discoveries demand changes are much more deeply embedded (and widely held) in our environment, our lifestyle and our culture than any standard in medical treatment could ever be. The more complex and deeply rooted the norm the harder it is to change. For far too many years advertisers trumpeted the ‘cool’ of smoking, transportation systems evolved to preclude the need to move, agricultural policies promoted the procurement of refined carbohydrates…these and many other factors have had a dramatic impact on our modern lives, and are not easily reversed. Mindshare has been hard enough, let alone behavior change.

Third, there is no field or profession that is explicitly tasked with bringing about these changes. Or if there is, it is inconceivable that any one individual, group or even sector can move the needle across large populations on such deeply embedded behavioral norms.

So who is responsible? And who can bridge the gulf?

The only answer that will suffice is everybody.

To change the way large populations eat, move, sleep, and essentially live will require meaningful contributions from all corners of society. Governments must redact policies that are detrimental to public health, and replace them with those that promote healthful behaviors. Academics must investigate not only the relationship between behaviors and health outcomes, but  how to most efficiently close the gulf between knowledge and practice. Healthcare purchasers must transcend complacency in managing risk, and proactively mitigate risk. Schools must engage their students, companies their employees and communities their members. The private sector, technologists and entrepreneurs must create innovative (and monetizable) technologies, strategies and solutions with which to enable people to improve their health behaviors. And every single individual must take responsibility for their own health behaviors while influencing those around them as they are able. Because if the gulf persists, we all lose.

In public health as in medicine, there is an enormous latent opportunity that derives from consistently executing what we already know to be right. Scientists will continue to make new discoveries about which behaviors lead to optimal health - but while they do it’s up to everyone else to do their part in closing the gap between what we know and what we do. The reward could not be overstated.

If you are working at the intersection of health and technology, there is a lot to be excited about these days. A plethora of tech solutions are emerging that enable people to pursue a more healthful lifestyle. There are devices and apps and games for exercise, nutrition, sleep, smoking cessation, stress management, etc. There are trackers to help you objectively quantify your behaviors, which generate reports to help you monitor your progress and draw inference about your health. There are virtual coaches and reward systems to motivate you to progress toward your personalized goals, and online social networks that provide peer support along the way. Technology is pioneering new solutions to difficult societal problems. Yay technology!

But when you take a step back, it is interesting to note that many of the behavioral health issues of today were in fact themselves caused by technological innovations.

Though our hunter-gatherer ancestors had plenty of health issues, physical inactivity, refined carbs, metabolic disorder and the like were definitely not among them.

Since the paleolithic era, a series of technological revolutions have enabled dramatic advancements in society, and have greatly improved quality (and quantity) of human life along the way.

Around 10,000 BC the agricultural revolution brought about the decline of nomadic existence, the first instances of excess food production, division of labor and new opportunities for people to focus on things other than survival. It also introduced a dramatic divergence between the foods that humans are evolutionarily programmed to consume and the typical human diet — a gulf that has continued to expand ever since since.

From the 18th to 19th century the industrial revolution again affected nearly every facet of human life, facilitating dramatic economic and population growth. New technologies created substantial efficiencies around agriculture, transportation the production of goods and procurement of energy - substantially impacting living standards. The industrial revolution also mechanized numerous activities that erstwhile required physical labor - from farming to the production of goods and transportation.

We are now amidst a digital revolution, characterized by tremendous advancements in the access to and transfer of information. The benefits are vast - if you are reading this blog you are enjoying them presently so I won’t elaborate. But along with these never before imagined conveniences has come yet a further digression from our evolutionarily programmed, hunter-gather lifestyle. Hungry? Calories are a click away. Lazy? Walking is so passe. Housework? Switch on the Roomba. Got to go to work? SUV to Deskjob and back!

Many of the behaviors that were once essential to survival - like the ability to traverse double digit miles a day in between evading predators, conserving fat stores, and hastily building shelter - have been almost entirely engineered out of our lives. Tens of thousands of years of natural and sexual selection turned on their heads.

I do not mean for one second to suggest that I would prefer to return to a hunter-gatherer existence. I rather like running water, antibiotics, thai takeout and the internet. But it doesn’t take a rocket surgeon to notice that there have been some very serious unintended consequences to technology-enabled human progress. If it was our goal to procure high caloric density foods and other amenities with minimal effort - perhaps we overshot a tad. Imagine trying to tell an early homo sapien that today obesity afflicts, and kills, more humans than hunger.

Through medicine and epidemiology we’ve identified numerous behaviors and other risk factors that are causing modern chronic disease epidemics. These are diseases that were virtually non-existent among hunter-gatherers. These behaviors are, unsurprisingly, examples wherein human behavior has dramatically diverged from that of our paleolithic ancestors.

And now technology is emerging as a solution to problems caused by other technology…to offer corrections to past progress. (ok so I am sort of trying to riff on Jonathan Franzen but its probably too obscure so there you go)

Technology alone will be insufficient to fundamentally change the way many people eat, move, sleep, manage stress and generally balance their lifestyle. There are fundamental contributors to poor lifestyle behavior - built environment, social norms, access to fresh foods, education, etc. But technology can certainly be a sizeable part of the solution - a tool that individuals and organizations use to meaningfully and cost-effectively improve lifestyle behavior on a large scale.  

The risk of further unintended consequences looms large. Obsessive tracking might cause neurosis. Health gamified too well might lead to addictive behaviors. It is not unlikely that further corrections will be required.

But it is reassuring to see how technologies can be successfully deployed to introduce corrections to unintended consequences of prior innovation. The rate limiting step - and the reason why, say, obesity continues to gain in prevalence and detriment - appears to be our ability as humans to identify unintended consequences and rouse the cultural, economic, political, and individual will to take action to address them. I guess corrections take time.

Organizations of all kinds are increasingly turning to game dynamics to shape peoples’ behavior. But the promise of gamification in the health behavior space remains to be determined.
                   
Three-quarters of healthcare spending in the US can be attributed to epidemic levels of chronic diseases (like heart disease and diabetes) that are largely preventable with healthy lifestyle behaviors.

The disparity between what is known about the behaviors that drive optimal health outcomes and the average American lifestyle is enormous, and growing. Eliminating the gap between what we know right now and what people do would yield greater human and financial value than any conceivable medical advancement.

The problem is, changing peoples’ behavior is really hard. To begin with, the deck is stacked squarely against many Americans who, from a young age, have lived in social and physical environments wherein poor health behaviors are the default, or who lack the time or money to take positive action. However my point is that, even in cases where individuals have the knowledge and means - and often genuine motivation - to pursue a healthful lifestyle, many do not, or at least struggle to do so.

There have been many logical, evolutionarily sound rationales for why this is the case, put forth by clinical psychologists, evolutionary biologists, behavioral economics and everyone in between. Just one example, what Socrates referred to as ‘measurement error’, wherein people perceive definite proximate pleasures (eating chips NOW) as being relatively larger than nebulous distal pains (increased risk of heart disease, 20 years down the road). The cognitive-emotional issues and biases at hand are often deeply rooted and, obviously, very difficult to overcome.  Many of the same experts that identify these biases put forth strategies to overcome them. These range from health education to emotional counseling to peer support to behavioral tracking to….the list is long.

The concept of gamification - applying the same mechanics that make video games engaging to the point of being addictive in order to influence more general behaviors - has exploded in popularity over the last couple years. The gist is that people are universally motivated by things like reward, competition, status, achievement, self-expression and altruism - and these psychological drives can be tapped in order to motivate people toward a desired behavior. Like spend time on a website, buy a product, or donate to a cause. Concepts such as points, levels, badges, rewards, and leaderboards are common ingredients. This is by no means a new concept; airline ‘status’ miles are often cited as a quintessential example of an industry that has successfully gamified consumption of its service. However, the relatively recent emergence of numerous gamification companies (e.g., Bunchball, Big Door, Gamify, Badgeville, etc.) is indicative that gamification has gone mainstream.

What promise does gamification hold in helping people to change their health behaviors?

There are a few concepts here that I think are work exploring.

First lets compare health gamification to video games. The reason that video games are so effective in tapping into human psychology is that they allow motivational drives to be fulfilled vividly, simultaneously and instantaneously (and all on the same screen). Maybe an inappropriate analogy, but they are like crack. Very addictive. On the other hand, when you apply game dynamics to influence health behaviors it inherently involves an extra step - the health behavior itself! Whether that behavior is exercise, nutrition, tobacco reduction, sleep, stress management or whatever - you have to go DO it - then come back (say, to a screen) to get your reward, achieve a status, etc. I see this as vegetables coated in crack. The feedback loop between behavior and response is delayed - and buying, cooking and eating health food is a lot harder than manipulating a remote (at least for most of us). This doesn’t mean that game dynamics will be unsuccessful in motivating health behavior change - but I don’t think we should always expect engagement on par with WoW or Farmville.

There is also a lot of individual variation around motivation and overall readiness to change or engage in a health behavior. I see it as inertia or ‘activation energy’ (to borrow from my high school chemistry teacher). For those who are already fairly motivated and ready to change (and have the wherewithal to do so), gamifying the behavior change might just be the spark that gets them over the hump. For others, it won’t even come close. Environment, cultural norms, and decades of conditioning tower over points and badges - more fundamental (and often very difficult) issues need to be addressed. This is definitely something to keep in mind for health gamification efforts that use employers or other health payers as channels to reach users (see my previous post ‘A Tale of 2 Health Engagement Solutions’) that may not want to be reached. If the goal is to influence the least well off - I think that game dynamics come at the top of a tall pyramid.

Just as the user’s state of being influences the likelihood of success, so does the quality of the health engagement experience, product or solution that is being gamified. Adding game mechanics to an already high-quality, engaging experience is like putting frosting on a good cake (again, bad analogy, sorry) - most people will probably like it even more. Gamifying a pointless or frustrating experience or product is like putting frosting on a steaming pile of $%&# - it still smells bad and it makes people angry.

In my opinion, there are a good number of organizations out there that either have, or are in the process of applying ‘Gamification 101’ to health behavior change before they’ve baked a good cake. Throw points and badges and leaderboards at a behavior that has proven very difficult to influence, and hope for the best. Though I am inclined to believe that such efforts may move the dial over the short run - a testament to the power of game dynamics - I think that they lack the nuance and subtlety and what I will call ‘fit’ with the user’s particular motivations and needs and desires required to engender lasting engagement - especially among those with relatively high activation energy. I’ll defer on proper nouns for this paragraph.

Then there are others who are either more thoughtful about their approach, or who have at least chosen a target user population with low(er) activation energy, and provided them with an intuitive and valuable experience that is augmented with game dynamics.

Take Fitocracy as one example, which uses seemingly simple gamification building blocks to make a fun and social game out of tracking fitness activities (I get the feeling they are primarily focused on strength training, but they accommodate a wide variety of activities). They have managed to engage a highly enthusiastic, and fast growing population of folks working out to ‘level up’ and in doing so unlock special challenges, achieve social standing, etc (fist pump guys). Whether Fitocracy can capture a broader audience - perhaps with higher activation energy - remains to be seen, but I think for now they distinguish themselves as having successfully integrated gamification to motivate fitness tracking in a way that very much fits the motivational drives and social context of their particular user base. 

This post is getting pretty long so I will defer exploring other examples of health gamification for a later post (MeYouHealth, Keas, Arookoo, Earndit, Health Month, etc. etc.). But I’ll close with two final observations.

First, just as Zynga has gotten where it is by nailing the intersection of social and gaming, I think that social is and will remain absolutely essential to success in the health space. This requires understanding and leveraging relevant social networks for health (which are, in my opinion, specific and unique subsets of the broader social graph).

Finally, the ultimate goal of any external nudge toward sustained health behavior change is to overcome activation energy, which will hopefully lead to a new behavior pattern, and finally to an intrinsic motivation to continue to pursue the new behavior independent of external stimulus. It is my view that game dynamics, along with tracking, rewards and a host of other motivational tools are all useful catalysts of this process. But there is no silver bullet. Health behavior change solutions will become more efficacious to the extent that they are able to do a better job at breaking down each person’s readiness to change, identifying what motivates them, and tailoring interventions accordingly.

I’ll revisit this topic again in the future as there is a lot that remains untouched. I’d also welcome your comments and ideas, as I am learning as I go here. 

For some time there has been broad recognition that the US healthcare system has evolved, or perhaps devolved, to be incredibly frustrating for patients. We’ve all heard the pundits talk about how US healthcare is the best in the world when it comes to emergency care, but often fails to manage chronic conditions (which drive around three quarters of healthcare spending in the US) in a way that is effective or efficient, let alone convenient for patients. The reasons underlying this failure are debated. Some might blame our predominantly fee-for-service reimbursement system - only when doctors are paid to provide high value care and keep patients healthy will patients receive the best quality and convenience of care. Others might site the fact that because of the perverse nature of insurance in healthcare, the patient is not the real consumer, is not ‘paying the bill’ in the eyes of other healthcare stakeholders - and as result is not given quality customer service.
 
Maybe Accountable Care Organizations (ACOs) will revolutionize the way that networks of providers cooperate to provide high-quality patient care. Maybe consumer-directed health plans will become ubiquitous and patients will assume the role of direct consumer for more and more care. Maybe patient-centered medical homes will establish the primary care physician as the patient’s advocate for all of their healthcare. But that is not what this post is about.

Despite the fact that the success of these and other reform initiatives remains to be seen - another kind of transformation is already taking place that is empowering patients to be more informed consumers, and get higher value healthcare.

Over the last decade, a number of consumer facing healthcare technologies have emerged that are in one way or another trying to make some part of the patient experience better.

A quick sampling includes (this is by no means a comprehensive list):

• Finding medical information: Google, WebMD
• Getting answers to medical questions -  Sharecare, HealthTap
• Understanding and paying healthcare bills - Simplee, Cake Health
• Comparing the quality and cost of providers and services - Castlight, Healthcare Blue Book
• Managing and sharing your medical records - Dossia, Healthvault
• Talking to a doctor from the comfort of your home - Hello Health, American Well
• Making a doctor’s appointment - ZocDoc
• Investigating a symptom & finding a local hospital - itriage

Whether these and other patient empowering technologies will merely help patients cope around the margins of a dysfunctional system, or whether they’ll catalyze more fundamental transformations toward patient-centered healthcare remains to be seen. If I were a gambling man I would bet on the latter.

Though most of the technologies on the list above have serviced but a small fraction of US patients - that was once the case for Google - and now well over half of US adults use the internet to search and access health related information.

When patients are empowered with the basic information they need to be discerning about their care (e.g., their health data, and the costs of care and quality ratings of doctors and hospitals) and when they get a taste of convenience in healthcare (e.g., EOBs replaced with convenient infographics, clear statements about what is owed, and options of auto-payment) they’ll start demanding more from the healthcare system that has under-delivered for far too long.

Or perhaps not more, but rather better, and more convenient.

I’ve been thinking a lot recently about the distinctions between web/mobile health engagement solutions that have been designed to delight and engage consumers vs. those that have been developed primarily to deliver value to a healthcare stakeholder other than the consumer – typically an employer, health plan or provider – but in order to do so successfully must engender a change in user (employee, member, patient) behavior along the way.

Direct to consumer health engagement solutions presumably focus entirely on delivering some kind of value to the user – to help them do something they either want or need to do. That could mean helping them to track their blood pressure, access a social network that encourages them to lose weight, or save money by better managing their healthcare spending. These solutions are most often monetized through ads or (freemium) subscriptions, so achieving large numbers of engaged users is a critical business objective. Typically, the user base is comprised of individuals who are early technology adopters and either already engaged in their health, or keen to be more so.

On the other hand, solutions whose revenue model stems from a healthcare stakeholder other than the user serve two masters. Their paying customer is an entity that has a vested interest (often a financial one) in fostering some kind of behavior change among its members/employees/patients. These solutions’ user base is (obviously) comprised of the individuals that this stakeholder wishes to influence.

In the latter case, these particular individuals do not necessary want or (in their opinion) need to change their behavior in the way that their sponsoring entity desires. Though they (almost always) sign up for the solution voluntarily, they may have been conditioned or nudged to do so in any number of ways (cultural, financial, etc.). And they are almost definitely not paying for the solution. Moreover, the type of individuals that a sponsor really wants to engage (usually because they incur the highest costs) are probably the least likely to (voluntarily) engage with such a health solution.

Finally, these solutions are judged by their paying institutions on (typically subjective) value – cost savings, ROI, etc. User experience and engagement are understood to be prerequisites of value – if nobody likes the product and nobody is using the product, it is unlikely to engender meaningful behavior change. But they are viewed as means to an end, rather than ends in and of themselves (and they have historically been treated as such). And engagement is rarely achieved to the extent that sponsor and vendor would like.

Due to the very distinct parameters that surround each of these solution types – from their revenue source to their user base composition and everything in between – it is not surprising that they are at least somewhat divergent in their nature and purpose. However, there are valuable lessons that each solution type might learn from the other - and noteworthy examples of vendors who have applied them successfully. Given the momentum toward consumerism in healthcare, I predict a continued convergence of the two. Techniques used by consumer facing web/mobile solutions that have successfully engaged early adopters will be increasingly - and more effectively - transferred to settings where a sponsoring stakeholder has the opportunity to provide additional nudges and incentives to encourage those less likely to engage. This creates an opportunity to do better at engaging many of the individuals who are most in need and stand to benefit the most from increased engagement in their health and care.

I’ll come back to this topic with more specific examples over time.