Economic rewards through 'automated hovering' help patient compliance

If the fear of a stroke or hemorrhage isn't enough to make people take their blood-thinning medication correctly, what is?

A University of Pennsylvania study found something: a computerized pillbox that automatically enters patients into a weekly lottery. If their number comes up, they win money — unless they didn't take their warfarin pill the previous day.

In the experiment, the rate of incorrect warfarin doses dropped from 22 percent to about 3 percent, and the percentage of patients with correct blood clotting levels rose from 65 percent to 88 percent.

"We tried to build a platform that would automate the process" of prodding patients to take their medicine, said David Asch, a Penn physician and health economist. "We've also done it with weight loss and smoking cessation."

In last week's New England Journal of Medicine, Asch and his coauthors argue that "automated hovering" is an idea whose time has come.

It is part of the burgeoning field of "behavioral economics," which aims to motivate people to change unhealthy behavior by tapping into their self-interest.

Unfortunately, it turns out to be more complicated than just bribing people to do the right thing, because the timing, accessibility, and context of the money matters. As Asch's coauthor Kevin Volpp explains, a $100 discount on an annual insurance premium may go unnoticed, while a $100 check in the mail may feel like a big windfall.

Hovering technology — including cellphones, wireless devices, the Internet — has the advantages of being automatic and offering constant reinforcement. It's also far less costly than traditional hovering, in which health professionals visit, call, and otherwise try to dog the patient into compliance.

Asch and Volpp now have a $4.8 million grant from Medicare to see if automated hovering helps heart attack patients take their medications after leaving the hospital.

Ultimately, they hope to tap even deeper self-interests. "Regret, self-esteem, social acceptance — these are far more potent than money," Asch said.