Are Epiphanies the Key to Fixing Healthcare?

Extrinsic Rewards Can Create An “Epiphany” to Unlock Intrinsic Motivations

Extrinsic Rewards Can Create An “Epiphany” to Unlock Intrinsic Motivations

Perhaps epiphanies are the key to fixing the healthcare system.  In an ideal world consumers would engage in healthy behaviors without any need for extrinsic rewards or other engagement tools and behavioral economic levers.  Unfortunately, for many reasons, most consumers simply do not. If we could tap into the intrinsic motivators of consumers, we could truly unlock each individual’s reason to be healthy and impact some of the negative consequences that result from behaviors such as poor nutrition, lack of exercise, little prevention, and the related lifestyle factors that drive the lion’s share of healthcare costs.

Given this reality, what we are really trying to do is optimize the use of tools like extrinsic rewards to unlock these more intrinsic motivators. We often talk about how extrinsic rewards can serve to drive lots of behavior, especially those behaviors that require discrete events (e.g., mammogram) or focus on short-term actions. However, over the long term, it is important that these extrinsic rewards, when combined with other engagement techniques and behavioral economics concepts, unlock an individual’s intrinsic motivations for behavior change.  Extrinsic rewards can do a lot, but they really serve their purpose if they can, in addition to driving shorter-term behavior, can be a bridge to an individuals’ intrinsic motivators.

How does this happen? How do extrinsic rewards connect the dots from shorter term or one off behaviors spurred by extrinsic rewards to the power of more fundamental intrinsic motivations?

We believe the answer is epiphanies. Webster’s dictionary defines epiphany as “a moment in which you suddenly see or understand something in a new or very clear way”. It goes on to offer similar definitions:

• sudden manifestation or perception of the essential nature or meaning of something
• intuitive grasp of reality through something (as an event) usually simple and striking
• illuminating discovery, realization, or disclosure

http://www.merriam-webster.com/dictionary/epiphany

All of these definitions stem from the ideas of “to show or manifest.”

Extrinsic rewards can serve to manifest for the individual impactful perspectives, feelings and emotions by exposing individuals to opportunities to which they might not otherwise have been exposed. The extrinsic reward drives the initial event (“Trigger Event”), and the individual is exposed to one of the following:

• Inspiration: an event or environment that inspires them.
• Diagnosis: a medical diagnosis
• Information: information about a health condition or risk
• Health Tool/Service: health service or tool that assists dealing with a health issue
• Results: a health results such as losing weight
• Relationships: interaction with or support from others
• Support: support from others that make dealing with a health issue easier
• Peer Pressure: pressure that comes from interacting with others
• Shame: the negative feelings that surface when an individual is ashamed of how they are managing their health

Once exposed, we hope that the individual has an epiphany – “a moment in which they suddenly see or understand something in a new or very clear way”. A few of these are described below with a real life story of how the extrinsic rewards led the individual to have an epiphany of sorts.

• Inspiration:exposure to a situation or individual that inspires them. This could be from a fellow patient, a caregiver, or another reaching new heights.
  • Story: Through Disney Healthy Pursuits, our employees can find support and motivation. Claudia Ball from Disney-ABC Television Group can testify to that. After her doctor advised her to lose some weight, Claudia looked into the Wellness Rewards Program. Claudia began working out at Disney’s Hyperion Fitness Center at the Studio Lot in Burbank, and has regular phone calls with a personal health coach. The health coach helps Claudia stay motivated by keeping her wellness goals top of mind and providing her with healthy recipes to use at home. Claudia says, “I started doing this for me. Now it’s for my kids, my family and my friends who need inspiration along the way, too.” http://thewaltdisneycompany.com/citizenship/reporting/report-archive/2010/disneyworkplaces/stories/

• Diagnosis:a medical diagnosis as a result of a test or interaction. This might include the result of a mammogram or a blood test.
  • Story: I was too busy to go for routine preventive tests suggested by my doctor. I was caring for aging parents and my mother was fighting breast cancer. Even knowing breast cancer was taking her life I still didn’t schedule an appointment for a mammogram. I felt healthy. After the “Rewards for Wellness” program was presented at one of my local union meetings, I promised my membership that I would participate 100% and asked that they do the same. A colonoscopy revealed a cluster of pre-cancerous cells, which were fortunately removed. The doctor told me how lucky I was because once pre-cancer clusters turn to cancer it can spread like wildfire. So I feel the wellness program saved my life! Please don’t sit there and say it couldn’t be me. Those were my words. I challenge you not to be afraid of what you may hear- be afraid of what you may not get to hear because you died a death that could have been prevented. Click here to listen to Lynn’s story. http://www.wellness.ri.gov/testimonials/

• Story: I always thought the Wellness Program was just a way to get monetary benefits until this year. At the Health Fair I found out that my blood pressure was very high, lot higher than ever.  This information scared me and it lead to really positive stuff.  I have lost weight since the health fair and I continue to exercise on a regular basis.   The awareness I received was awesome and it proved to me that the Wellness Program is not just a monetary benefit; it is a life changing benefit which is more important than the monetary benefit.  Thanks for the awareness; it has changed my life in a very positive way. http://www.wellness.ri.gov/testimonials/

• Information: information about their specific condition, symptom or risk that was unknown to them or understood by them before.

• Story: I went to a nutritionist just before the health fair and seeing my BMI and the hand outs and displays got me motivated, I am now exercising and eating more healthy.  My insulin levels and my weight are slowly coming down. Thanks. http://www.wellness.ri.gov/testimonials/

• Health Tools/Services: services and tools that make it easier to manage your lifestyle or health. This might include exercise trackers, food and nutrition management solutions, glucose monitors and heart rate monitors.

• Story: When Central Michigan University’s new employee wellness rewards program began in July, Stauffer, an administrative clerk in the registrar’s office, decided it was time for a new lifestyle. “Programs like this help us prevent future serious health problems. I knew I needed to do something to get my weight and blood levels in check, and this program gave me the push I needed, offering incentives and rewards along the way.” She began walking regularly and counting her calories, using tools provided through the program. When Stauffer recently visited her doctor to have her cholesterol levels checked again, he told her they had improved tremendously. Thanks to her new lifestyle, she eliminated her need for cholesterol medication and is turning her health around.  Stauffer shared tips to her success with the help of the rewards program.“I use the Max activity tracker to count my steps every day. I also use MyFitnessPal which is incredibly helpful. Not only does it help you track your calorie intake, but it also tracks your sodium content, carbs, fat, protein and sugar intake — all things that I had been overlooking before.”

• Results: a specific result gained from a positive health behavior. Examples include weight loss, clothes fitting better, reduction in a biometric value, or improved cholesterol.

• Story: I just submitted my final week’s totals for the Physical Activity Challenge. It was a wonderful experience. As I completed the exit survey, I thought one other question might have been interesting to ask participants: “Do you plan on continuing the physical activity routine you developed over the past 5 weeks?” I know I will. This 5 week program was long enough to be incorporated into my daily schedule and become an activity I looked forward to, not just a fad or a class. I lost 12 pounds and feel great! I walked everyday and incorporated into my morning routine a 45 minute abdominal routine on a CD as well. Thanks for putting this wonderful program together. I got involved for the financial incentive and ended with the health benefit- as the icing on the cake, so to speak. http://www.wellness.ri.gov/testimonials/

• Relationships: connections with individuals such as individuals with common conditions or issues or caregivers. This might include fellow pregnant women, relationships with providers or nurses or with fellow employees in a company.

• Story: “This program is particularly fun because so many people in my office are participating. We can do things like walk together, compete against each other, compare points and share challenges. Plus, the $100 reward for reaching 8,000 points keeps me extremely motivated!”

• Support:support groups that assist with dealing with a common health or personal issue.
  • Story: Well here’s a program from the UK that shows exactly how this can work. The UK offered a program in which Moms in three areas of Derbyshire and South Yorkshire where breastfeeding rates were low – between 21% and 29% – could earn shopping vouchers of up to £200. Of the 108 eligible for the trial scheme, 58 signed up and 37 (34%) earned vouchers for breastfeeding at six-to-eight weeks. But perhaps more importantly, read carefully how the rewards acted as the initial impetus that then exposed the individuals to a series of benefits that made the rewards secondary over time. Listen carefully to what one of the mothers said. Vanessa Purdy, 31, who is still breastfeeding her eight-month-old, James, said: “The vouchers lure you into the scheme and breastfeeding. But the confidence you gain, and the friends you make through the scheme, is unbelievable. She also said:
    • “It’s that support network, not the money, that spurs you on to continue.
    • “It broke down the barriers and got everyone talking about the vouchers.”
    • “It made breastfeeding feel normal and natural to me.”
    • “And the money was useful for daily shopping and a few treats. I even tried tuna steak for the first time.”

• Peer Pressure:pressure resulting from other individuals engaging in positive health behavior.
  • Story: our company reward program really got us involved. In particular, our office was determined to score higher on the biometric measures than our counterparts at corporate.  We had earned rewards for taking the tests and then could earn more incentives for reducing our BMI. And then something strange happened. We were all using Fitbits in our office and there was pressure not to be the weak leak on the team. We all used to kid that we were in it for the money but when our colleagues were all ribbing each other when someone fell behind on their steps, it really pushed us.

• Shame:the negative emotion of realizing that the individual is ashamed of how they are handing their health situation. 
  • Story: it was a real wake up call for me. I was pregnant and under a lot of stress and just wasn’t following my pre-natal care like I should have been. Our company wellness program had lots of tools and information for me including incentives I could earn. But I still wasn’t paying attention to it and I knew in my heart that I was not doing the right things for me or my unborn child. A co-worker let me know about the maternity program and the reward I could earn to if decided to do it. I’m embarrassed to say that my initial motivation was the money but I am glad that I did it. It forced me to go to one of the sessions and all I could think about was how ashamed I was that I was not taking care of things the right way. I was surrounded by other women that had so many more complicated pregnancy issues than me.  I was so ashamed of myself and told myself that I was going to do it from that point forward.  I feel bad today that it took my own feeling of being ashamed of myself but in the end, it moved me to follow the right path of care.

The key is structuring the extrinsic rewards so it accomplishes several goals. First to drive the short-term or discrete behaviors that they target. Second, to expose individuals to the various opportunities listed above and to do so with the frequency that an epiphany is possible. For example, while getting a mammogram only requires a one-time event to be exposed to a diagnosis or information, a support group may require multiple interactions before the individual can have an epiphany that the group may really help.

Hopefully, by thinking about how we might drive these epiphanies, we can both lead the horse to water, and have an epiphany about what it would mean for them to take a drink. This clearly is not a scientific analysis of behavior. On a simple level, perhaps it is an iteration of Self-Determination Theory  which is described at www.selfdetermination.org as follows:

“People are centrally concerned with motivation — how to move themselves or others to act. Everywhere, parents, teachers, coaches, and managers struggle with how to motivate those that they mentor, and individuals struggle to find energy, mobilize effort and persist at the tasks of life and work. People are often moved by external factors such as reward systems, grades, evaluations, or the opinions they fear others might have of them.  Yet just as frequently, people are motivated from within, by interests, curiosity, care or abiding values.  These intrinsic motivations are not necessarily externally rewarded or supported, but nonetheless they can sustain passions, creativity, and sustained efforts. The interplay between the extrinsic forces acting on persons and the intrinsic motives and needs inherent in human nature is the territory of Self-Determination Theory.”

I hope not to offend the true behaviorists, but perhaps looking for these epiphanies provides some insight to how extrinsic and intrinsic motivators help to achieve our common goals of health improvement and cost reduction.

epiphany / shutterstock