Ep #493 Behavioral Economics in Healthcare - Matt Loper | ShiftShapers

Speaker 1: 0:00

How can plans use behavioral or economics to achieve better outcomes? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:09

Change either energizes or paralyzes. The choice is yours. This is the Shift Shapers podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry shifts. And now here's your host, david Saltzman. Interviews with individuals and companies who are shaping the industry's shifts. And now here's your host.

Speaker 1: 0:29

David Saltzman, and joining us today to discuss that very topic is Matt Loper. Matt is CEO and co-founder at Wealth. Welcome Matt.

Speaker 3: 0:38

Hey, david, thanks so much for having us.

Speaker 1: 0:44

It's our pleasure. I'm always asked this question. Tell us a little bit about your background, because people usually have circuitous paths in our industry to where they are doing what they're doing today. How did you get here?

Speaker 3: 0:52

Yeah, Do you want the long version, the medium version or the short version?

Speaker 1: 0:56

It's your 25 minutes. Spend it how you want.

Speaker 3: 0:58

Awesome, yeah, so I'll give you the medium version. Okay, I was a bio nerd all growing up, wanted to be a biologist, wanted to start biotech companies someday, went to college and studied bioengineering and very quickly learned that you know, all my professors were literally the top in their field and worked 30 years in a lab to hopefully find that one discovery that became a lifesaving therapeutic. So realized that I was almost certainly not as smart as them and didn't have the patience to wait around 30 years to see if I had that one in 30 chance. So figured out how, how do I get into the healthcare space or the biotech space specifically, more quickly? Um, went to wall street to try to learn uh, you know how to value companies, invest in companies, hopefully, help start many biotech companies a year. Uh, at that point, you know, got put, helped start many biotech companies a year. At that point, you know, got put.

Speaker 3: 1:45

You know, like many things in life, by chance onto a project working with at the time Anthem, now Elevance and this is 2010 or so.

Speaker 3: 1:59

We were hired by the board to kind of do a complete strategic review of their business and at the time I was like health insurance, that's so boring. I wanted to do the cool biotech stuff, but it ended up being by far the most fascinating project I worked on. Saw, you know, kind of all these changes coming to market with the Affordable Care Act being implemented, with value-based care coming online, went on to an investment firm and had the idea that, hey, maybe I won't save lives creating new proteins or drugs or you know therapeutics, but maybe I can help save lives creating new proteins or drugs or therapeutics. But maybe I can help save lives using behavioral science and technology. So we've been at it for about 10 years now. It's been by far the hardest thing I've ever done, probably three times harder than I ever expected. But now that we're at a point where we can actually measure the impact we're making on the populations we serve, it's at least 10 times as rewarding. So it's been a long and strange journey, but I wouldn't have it any other way.

Speaker 1: 2:50

So let's talk a little bit about the problem that you're working on solving. Where did the interest come from? What's been the glide path of starting and learning and getting to where you are today?

Speaker 3: 3:03

Yeah. So the problem that we're fundamentally solving is that the folks who really are driving cost and quality most for the health plans we serve tend to be the folks who are least engaged quote unquote in their own health. And that word engagement is a loaded term, right. But when we think about engagement in any other area of our life, we think about things like, oh, I'm going to sit down and watch one episode on Netflix and then six hours flies by and we binge the whole series, right. Or I get in this TikTok or Instagram loop where I'm scrolling for hours, right. That sort of engagement where we're just totally hooked, is completely different than when we talk about member engagement or patient engagement in healthcare. So in healthcare, when we think about engagement, it's receiving a text message or receiving information about things that you should go do, right. So we fundamentally had the thesis from the very beginning that the folks who need the true engagement the most are those who are, you know, not going to respond to any sort of just outreach and saying, hey, you should go do these things, or more information about why they should go do them.

Speaker 3: 4:10

What we really thought from the very beginning was, in order to actually change these behaviors and improve the outcomes to cost and quality. We had to serve this very hard-to-reach population. Usually it's folks who have Medicare, medicaid or dual eligibility. Usually it's folks who already have many chronic conditions or behavioral health conditions or both, and usually it's folks who are already disengaged or non-adherent to care.

Speaker 3: 4:35

And in this population we really tried to understand why are these, you know, why are these folks not paying attention? Why are they not following through Right? And how do you use behavioral science, behavioral economics, technology you know kind of now a lot of the new LLM and chatbot and AI stuff to truly create that level of engagement that a TikTok shoots for in healthcare? So what we'd like to talk about is hey, we can work with a senior population, you can give us the people who currently aren't enrolling in care management or any of these programs and we can get those folks to be three times as engaged on a daily basis over the course of a year than TikTok does in teenagers. So that's what we're trying to fundamentally solve is that behavior problem, that attention and behavior and habit problem in healthcare that leads to cost and quality outcomes for the plants we serve?

Speaker 1: 5:27

And you're not owned by the Chinese government, so that's even better. So why, in short, why aren't people adherent to stuff that they know is good for them? Is that just human nature? And how do you bring them back into the fold?

Speaker 3: 5:40

Yeah, so it is based on how we evolved as humans. Our reward systems in our brains are motivated by the instant, intangible graphication we get from doing any behavior. Right. So we aren't good at looking at the long term. We don't this.

Speaker 3: 5:54

Behavioral economists call this either hyperbolic discounting or present bias. We're biased towards the immediacy of the behavior or the reward we get from doing that behavior. The immediacy of the behavior or the reward we get from doing that behavior. So you know. Perfect example is when you get a new puppy right, like my dog up here. You can see, when you train that puppy they say, as soon as they do the trick, give them the treat right away. Right, so that immediacy is really important.

Speaker 3: 6:17

So we know what we should do, right, you know there's all the general wellness things that people know, like we should eat healthy, go, take certain steps a day, work out whatever it is. But for these folks that have chronic diseases, behavioral health diseases, substance use disorders right, the stakes are even higher and the number of things that they know they should do over the course of the day are numerous, right, take all your medications as prescribed. Show up for all the doctor's appointments. Track all the metrics on a daily basis. Right, you know close care gaps. You know kind of do all that every every few months and so there's a daily component to this. You know managing, managing these conditions. So we know, as humans, we know we've been told like, hey, if you have high blood pressure or type two diabetes, like you should be taking that blood pressure medication or let metformin. We know it's going to prevent that heart attack four or five, 10 years from now, but when you take that medication right now we feel no different, right now. Right. So that's that present bias gap that creates this gap between intent and behavior.

Speaker 3: 7:16

Right, we know the things we should do. Oftentimes we intend to and want to do the right thing, but if it doesn't give us that immediate gratification, we often don't end up doing it. So we, for 10 years, have tried to combine all sorts of concepts from behavioral economics, habit science, motivational interviewing, peer support, all these different approaches into one program that gets a hold of more folks, gets more folks to enroll in and start using, gets a hold of more folks, gets more folks to enroll in and start using, and then gets them again very hooked to this daily behavior. So 91% of our users give us their daily attention Every day. They're giving us their daily attention and completing these behaviors so that each point in time right.

Speaker 3: 8:01

What I like to say is, if you're going to try to create change to cost and quality, you can't cram for the test, right. You can't just study the night before right. You can't just turn around a three-star Medicare Advantage plan into a four-star plan at the end of the year, right before the end of the year, right, every day. If you just create this relationship with the member and every day create this gentle nudge towards these right behaviors over the course of time, you're going to create exponentially more improvement than if you just try to give them a shove once a year and push them in the right direction once a year.

Speaker 1: 8:29

Can you quantify the problem? What is this costing us?

Speaker 3: 8:34

Yeah, I think if you just think about STARS ratings as the one, you know, example of one problem we solve on behalf of health plans for Medicare Advantage plans, right, this is a huge, huge financial problem, right? Last year, CVS Aetna lost a billion dollars of stars bonuses. Centene and Elevance each lost about 500 million of stars bonuses. So the financial implications are huge. And when you look at how stars ratings were calculated previously, about two-thirds of stars ratings were the things that the plan controlled, so admin measures and caps.

Speaker 3: 9:04

So, do you have a call center that picks up the phone on time? Do you adjudicate claims on time? Do you have a network that your members are happy with? Right Now, this year going forward, two-thirds of the STARS metrics are based on the things that the member controls, right? So Part D, adherence, HEDIS outcomes, health outcome surveys, health equity index right, these are the things that now, like you have to, if you're going to be a profitable Medicare Advantage plan, you have to hit STARS bonuses. Cms is purposefully making it harder to hit STARS bonuses and now the things that you need to improve in order to hit those bonuses are all in control of the member. So that's why you know we think it's so crucial, especially Medicare Advantage, right now, to have a strategy to influence these daily member behaviors that impact these end metrics.

Speaker 1: 9:51

How do you reach out to folks? Is it like an initial human reach out and then an app after that, or is it human all the way through? How do you do that? And also, on your intake, how do you determine I mean, years ago they used Prochaska protocols and those kinds of things how do you determine whether a member is actually ready to make change?

Speaker 3: 10:10

Yep, yeah. So on the first piece, selecting for the membership that we're most interested in, actually we try to select against ourselves, right. We try to select for the people who are least adherent, least open to change, you know, because those folks tend to have the highest impact on cost and quality, right? And then how do we reach out? Well, it's a lot of, you know, learnings over the course of 10 years and millions and millions of data points. So, even just down to you know who reaches out to which member at what time with what message, right? So if we're enrolling, you know, let's say, a Medicaid single mother of three in New Mexico, we might reach out on the weekends because she might be working during the week. And we've learned that over time through hundreds of thousands, if not millions, of other contact with other members from the exact same demographic.

Speaker 3: 11:03

Versus the Medicare Advantage member in Grand Rapids, michigan, maybe we've learned that calling them at Tuesday at 3.15 pm during the first commercial break of Price, is Right, is the optimal time to get them on the phone, right? So just getting their attention is the first step. We do a lot of other things like here's an example of a postcard that is one of our clients Gold Coast Health Plan, one of the great county-based health plans here, medical health plans here in California and we reach out with a postcard that looks like it's a handwritten note Well, guess what? This was written by a robot. But it just tries to reach the member in the right format over the course of time so that then, when they get that phone call, they already have knowledge about the program. They know what it's about, we can answer their questions and get them enrolled into the program as easily as possible.

Speaker 3: 11:54

Then, once they're on, the app does all the work, right. So the daily engagement is all through the app. For example, let's say, medication adherence is a key portion of this program with Gold Coast right, that member might get a notification it's time to take your medications to avoid the loss of two of your $30 that we already endowed you, right? So that extrinsic reward, that part of behavioral economics that we use to get more people to sign up and then create this behavior, is then tied back to that immediacy right that we talked about. So they open the app, they snap a photo of the pills in their hand and they get this instant. You know, graffiti or confetti comes out. Great job. You've kept your $2 for the day right so that engagement on a daily basis and the reinforcement on a daily basis is all handled by the app over the course of time.

Speaker 1: 12:40

That's interesting. It's kind of like getting likes and getting that little endorphin rush. That happens when you know, even though they're meaningless in this case, you know they're pretty meaningful Do the plans that you work with? Just an oddball question do the plans that you work with market this as a feature of the plan?

Speaker 3: 12:57

Yeah. So we are very careful not to do that for a few different reasons. We're a quality improvement program. We're not a supplemental benefit, so we're not offered to the whole membership especially Medicare Advantage, I see. So we don't want to create any perverse incentive to sign up for that health plan or undo marketing efforts that that would run afoul of any CMS guidance. So we're very careful not to do that broad messaging. However, once the member is identified as an eligible member for the program, we try to do very, very targeted and strong messaging to that member.

Speaker 1: 13:32

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Speaker 1: 14:08

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Speaker 3: 15:00

Yep, yeah, so you know we take on all the program support related to the program itself on behalf of our health plan clients. So, yes, absolutely, members contact us. About 80% of the questions come through text message through the app. About 20% come through phone calls.

Speaker 3: 15:18

But there's been cases where we have one anecdote of a Medicaid single father who was going through some housing insecurity issues, had four children and the health plan that we worked with the Medicaid plan we worked with had a full team of case managers to help with this exact issue with housing stability.

Speaker 3: 15:42

The member wouldn't talk to the health plan case manager. It was this game of telephone where they were interacting with us every day through the app. They were texting us through the app giving us updates on hey, we need to get birth certificates for all three or all four kids Like, and then we would pass that information back to the case manager. The case manager would say, okay, tell them this because you know they trust us right, once they start using the app every day, they trust our team more than they trust the health plan's team and they see us as this nice extension of the health plan. So it's a very tragic example, but one where you know, because of this daily relationship, we were able to serve the needs of both the health plan client and the member in a moment of crisis, in a way that we never were designed to right, and this daily interaction is the thing that generated that touch point in order to solve, for those, you know, that emergent situation.

Speaker 1: 16:28

Yeah, well, I mean pretty much every study that I've read over time is that this all success in this area all revolves around trust and building trust relationships. Are there other ways that you do that, just in addition to people just using the app on a regular basis?

Speaker 3: 16:43

Yeah, and I think it comes back to our number one core value as a company is the member, is the mission right? So when we think about our personal goals or our company goals, it's all in the form of how do we serve the members. How do we grow, not for financial metrics, but because we want to scale the impact we've been able to generate. How do we, in any situation, show up in a way that is in the best interest of the member and not ourselves, not our company, not the health plan. Yes, we want to make sure we serve the needs of the health plan, not the health plan. Yes, we want to make sure we serve the needs of the health plan. But if there's ever an example which, luckily, in almost every case, the interests are all aligned right, what is best for us is best for the health plan and best for the client and best for the member.

Speaker 3: 17:26

But you know, if there was ever an example where there was a question is always choose the member first, right. So I think that you know, is a very basic thing. But if you start your organization and your culture with that core tenant and every all hands meeting or every board meeting, we start with playing a member testimonial and the videos that our members are sending back to us, and it reinforces that mindset that you know, hey, we're always doing what's best for the member. And that little thing again compounds over the course of time and builds. And then you know, your support agent, who you know is new to the company, you know, gets that ingrained in their mindset and then they show up in a way when there is that situation, in a way that serves and builds trust with that member. So I think it really impacts everything we do, from how we design our app and our technology, how we sell to the market, how we serve the members on a daily basis.

Speaker 1: 18:22

For a long time, when we talked about compliance, we were talking solely about medication adherence. It sounds like you guys do a whole wide range of things. When you engage with a plan, do they have the opportunity to tell you what they want to zero in on and how does that work? And then do you find that those engagements expand over time after you've shown success in whatever area they're initially interested in.

Speaker 3: 18:47

Yeah, absolutely so. Medications are still the primary focus for, at least initially, for a lot of these members and a lot of these use cases, because they are going to be the highest impact behavior you can change to improve STARS outcomes and improve cost of care. So, across all these different condition sets that we serve, medications are probably still the primary use case in every single case. So, to put hard numbers on it, we'll verify about 20 million member behaviors this year. Over 80% of those will be medication related tasks. However, to your point, there are so many other behaviors that have to happen either on a daily, weekly, quarterly or annual basis that also impact the outcomes of that population right. So we've done everything from care gap closure right, showing up for A1C visits, showing up for even dialysis appointments.

Speaker 3: 19:41

We worked with Davida on a really cool pilot where we were able to show an improvement to not just the daily medication adherence, not just. You know, people who have ESRD or on dialysis have very stringent nutritional guidelines. They have usually many, many chronic conditions beyond you know, just that kidney disease or that ESRD and they still have to show up in a dialysis center three days a week and sit in that chair, and a lot of these folks might be frail or elderly or not have the ability to get to that appointment right. So we were able to show that even that behavior of showing up we could improve drastically. We've done a lot of remote patient monitoring use cases where most of our Medicare Advantage populations have, you know, a daily remote monitoring behavior, whether it's blood sugars or blood pressures. So, yeah, so basically, we started very focused on the medication problem, but since the framework and the technology we've built is all about changing behaviors and framing these behaviors in the form of new habits, we've been able to extend beyond medications to any behavior that impacts cost and quality.

Speaker 1: 20:47

And I would presume that you're also pretty heavy on metric delivery and data delivery to the plans. Is that something that they have access to on a regular basis, or is that a quarterly? How do you guys do that?

Speaker 3: 21:00

Yeah, so there is daily reporting that is available to care management and some of the clinical pharmacy team on the more real-time stats on an individual metric basis. Stats on an individual metric basis, but really for more of the executive layer or the buyer, the champion of the program, we're doing quarterly business reviews where we start looking at those hard outcomes as it relates to claims, so cost of care and utilization reduction, and also those key quality metrics if it's especially a Medicare Advantage plan that's trying to improve their STARS ratings.

Speaker 1: 21:33

So you're 10 years into this. Where do you see yourselves in five years?

Speaker 3: 21:38

Yeah, it's interesting because it's like we've been doubling. You know, if you're using members enrolled, or therefore revenue, as the primary metric, we've been doubling our member account and our revenue every year for the past four years and we're now. It's so fun because it's 10 years in, but we're really just getting started, right, like it's one of those classic like overnight successes 10 years in the making, right? So, you know, especially in the Medicare Advantage and DSNP space, we're seeing so much interest that, you know like, I think in five years we hope to be the standard, right? We think that, you know, just like, every company needs a CRM and eventually every company ends up buying Salesforce, whether it's, you know, a good or bad thing, right? Eventually you all end up on Salesforce.

Speaker 3: 22:27

We hope that someday every plan, either the Medicare, a D-SNP or a Medicaid plan has a line in the budget and says we need the daily motivation tool to get our members to better cost and quality outcomes. And wealth is the de facto, you know, monopoly in that space, because we have, you know, now at that point, 15 years of data and hundreds of millions of data points and we're able to serve, you know, these populations in a way that no one else can because we have all those data insights on how to best change those behaviors, to impact those end outcomes, to cost and quality. So you know we're going from like the startup phase to now. You know we're kind of like trying to become the category defining and hopefully someday industry defining company in the space in terms of improving cost and quality outcomes.

Speaker 1: 23:12

That's awesome and a great place to end our conversation for today. Matt Loper, ceo and co-founder at Wealth. Matt, thanks for an interesting interview. We appreciate it.

Speaker 3: 23:20

Thanks so much.

Speaker 2: 23:22

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