March is National Kidney Month, and this year the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is turning its focus to what health plans and providers can do to better prevent and manage kidney disease in vulnerable patients.
Chronic kidney disease, or CKD, occurs when an individual’s kidneys become so damaged over time, the kidneys are no longer able to filter the blood as necessary—in turn leading to extra build up of water and waste. Additionally, this often results in development or exacerbation of comorbid conditions, such as heart disease, high blood pressure, or diabetes.
Although common, affecting an estimated one in seven adults in the U.S.—roughly 37 million—kidney disease can be difficult to spot in its early stages, allowing it to go undetected and, as a result, develop into later and more serious stages, including End Stage Renal Disease (ESRD). In fact:
Fortunately, even though kidney disease is common and difficult to detect, its progression can often be managed and prevented with the application of long-term, healthy habits.
The NIDDK has released seven preventative measures individuals with CKD can take now to better manage their condition, preserve their remaining kidney function, and slow the progression toward ESRD.
Still, adherence to these recommendations is easier said than done.
Human nature and the temptations of instant gratification play a critical, and often detrimental, role in preventing individuals with CKD from making the necessary changes to improve their health and manage their condition. Overcoming those barriers through a combination of digital health support and the science of behavioral economics, health plans and providers can begin to better help these members—and slow the progression of CKD.
Behavioral economics is the science that understands human behavior, our decision-making processes, and what it takes to create meaningful and lasting habit formation.
Unlike classical economics, which relies on mathematical frameworks to predict human behavior, behavioral economics relies on observed patterns of human behavior and decision making to predict future outcomes. As a result, behavioral economics identifies key barriers to good decision making, and allows us to overcome those barriers through deliberate strategies.
In healthcare, this means recognizing why our members don’t make healthy choices—even when they want to be healthy—and overcoming that intent-behavior gap to form healthy habits for better outcomes.
For example, John is diagnosed with stage one kidney disease and is told he needs to exercise more as well as reduce his intake of alcoholic beverages. While John is far from an alcoholic, and even enjoys the occasional weekend bike ride, making the changes to cut down on the after-work drinks with coworkers—and go biking instead—ends up being more challenging for John than he anticipated.
Even though John enjoys going for bike rides, willing himself to exercise after a long day of work proves difficult. Emotionally and physically drained from the workday, John lacks both the motivation and the energy to force himself to exercise and instead accepts the invitation of his work buddies to grab a pint or two at the bar across the street from the office before heading home—rationalizing that the days are long and he can still go for a quick ride after a drink. Unsurprisingly, John does not make it home on time, and does not end up going for a bike ride at all that week.
Understanding behavioral economics allows us to predict barriers to care plan adherence before they happen, and make plans ahead of time to address the multiple variables that prevent members from making healthy choices. As health plans and providers identify the present biases that keep members from forming good habits, and put in place programs that can motivate members to push past those biases through meaningful incentives, member adherence and subsequent outcomes improve.
Easy-to-use digital health platforms can help support members with CKD in building the habits necessary to slow the progression of CKD and achieve a better quality of life.
The NIDDK recommends seven preventative measures those wanting to optimize their kidney health can take to slow the progression of CKD.
By leveraging behavioral economics, digital health tools are well positioned to achieve lasting behavioral change.
For example, a digital health platform like Wellth might offer daily, personalized reminders to follow key care plan tasks (such as medication adherence or glucose readings), member support teams that can flag problems early on and provide support and accountability for members, and non-coercive (yet meaningful) financial incentives that motivate members to make the right choice. These supports help members prioritize their health—even when it’s inconvenient or it lacks the instant gratification that another, less healthy, choice might offer.
When coupling the seven preventative measures provided with behavioral economics-backed digital health programs, positive behavior change becomes incredibly possible—even for the most vulnerable patient populations.
Regular visits with a member’s care team are important to maintaining proper kidney health. With many cases of CKD showing little or no symptoms in their early stages, regular appointments with a provider become important to early identification of CKD.
Digital health platforms can help health plans and providers encourage these visits by flagging members who may be at-risk for CKD due to high blood pressure, heart disease, or diabetes and sending them a reminder to see their physician for a blood test measuring GFR. For members who have already been diagnosed with CKD, digital health platforms can be useful by offering in-app appointment reminders that notify and remind members about an upcoming visit—and collect real-time feedback if the member will not be able to attend and needs to reschedule.
When digital health automates these reminders and outreach, it saves provider clinics precious time in follow-up (with the average rescheduling call taking eight minutes) and reduces the administrative burden of having to call and remind each member manually. In addition, these reminders can save both health plans and providers from the rising cost of appointment absenteeism—which results in an estimated $52,000 to $250,000 in lost revenue for practices alone each year.
Type 2 diabetes and CKD often go hand-in-hand, making it critical for individuals with CKD to keep their glucose levels and blood pressure under control. However, only 26 percent of individuals with diagnosed diabetes report actually testing their glucose levels at least once a day.
While studies about nonadherence to prescribed glucose monitoring have listed several possibilities for why members are not using glucometers as prescribed—ranging from patient apathy to lack of testing strips to poor communication and education on its importance from providers—leveraging member incentives to improve adherence has proven to be successful.
In a program supporting patients with type 2 diabetes, care plan adherence—including use of prescribed glucometers—was measured by Wellth’s digital health platform and rewarded with a $75 reward that was redeemable at milestones throughout the program. As long as members remained adherent to their daily check-ins and associated tasks, the reward remained theirs. However, each time a member missed a day or failed to complete the assigned task, $2 was deducted from the reward balance.
Within three months of the program, the diabetes program achieved:
“Before the Wellth program, I was not checking my blood sugar regularly—only when I remembered to check. I found the program helpful in remembering, and I feel like I have more energy now.”
Wellth Member, diabetes program.
Medication adherence plays a large role in member outcomes, but members don’t always take medications as prescribed—and may even unknowingly take common medications like ibuprofen that can exacerbate kidney conditions.
While members generally want to be healthy, remembering to take medications daily as prescribed can be difficult when these individuals are balancing jobs, family and household responsibilities, and more. As one Wellth member, Carlixta, shares:
“I have been working as a caregiver for many years. I like to make sure that all my patients are clean, take their medication on time, eat well, and feel happy. To be able to achieve all this requires a lot of my time and my commute to my job is long. I leave home early in the morning and I return at night. I am in a constant state of rush. I have arthritis, asthma, and high blood pressure. I was not successful at taking my medication until I learned about Wellth.”
Digital health programs like Wellth improve medication adherence by using those same principles of behavioral economics to build a habit, one day at a time. For Carlixta, that meant getting a set amount of reward money at the start of each month and checking in to the Wellth app with a photo of her medications in hand each day as she was taking them. Each day she missed a check in, she lost a portion of her reward. At the end of the month, she was able to redeem whatever reward money she had remaining.
With flexible incentives, the rewards become meaningful as they contribute to a better quality of life for members—further encouraging them to remain adherent and develop these healthy habits of medication and other care plan adherence as appropriate. Carlixta continues:
“The financial rewards helped me a lot also. I am part of a low-income population. We work so hard every day for a basic salary. It is hard to be able to afford many things. We need to pay for rent, electricity, food, and medications.
With the rewards I received, I was able to buy shampoo, soap, some groceries, and vitamins. I feel it really is beneficial to have this kind of program available for us since it creates healthy habits for us and at the same time helps us have a better quality of life.”
The members in Carlixta’s program saw an average of 88 percent adherence, and reduced A1c levels as much as 2.5 over six months.
Maintaining a healthy weight is important for many facets of health, and kidneys are no exception. Extra weight can contribute to later health complications, including diabetes and high blood pressure—ultimately putting the individual at higher risk for kidney disease. And as kidneys work harder to filter above-average levels of waste due to obesity, the kidneys face an even greater risk of CKD.
Because weight plays a role in disease progression, establishing a member care plan that leverages digital health to support healthy meals and weight maintenance can help members stay healthier, longer.
The great news?
Just as extra weight can lead to high blood pressure and subsequently kidney disease, the reverse is also true. One good habit can help lead to other good habits, yielding better overall patient outcomes.
In a program with Mt. Sinai, a full-risk outpatient clinic, Medicaid members with Type 2 diabetes were invited to participate in the Wellth digital health incentive program—receiving rewards for adhering to prescribed medications and care plans.
Within three months of the program, the Mt. Sinai program achieved:
As members do the little things to take care of themselves, those little things over time become the big things—and help members make other good decisions like eating right, exercising, and taking care of themselves.
Listen as Wellth member Linda shares how Wellth’s medication adherence program was the stepping stone to a better, more well-rounded healthy lifestyle.
Stress and physical activity go hand-in-hand when predicting outcomes for individuals with CKD.
Studies have shown that high stress levels can lead to conditions such as diabetes, hypertension, and vascular diseases, all of which put additional strain on the kidneys and leave individuals at higher risk for CKD. As such, managing stress becomes an important part of preserving kidney health and function.
Regular exercise can be an effective method for both reducing stress and improving kidney function, with the NIDDK recommending 30 minutes or more of exercise each day.
Digital health platforms can help support healthy lifestyles by offering not only reminders and in-app education about the importance of exercise, but by connecting members with a support team that can keep members accountable and offer encouragement and notify relevant care teams when members start missing check-ins or otherwise struggle to adhere to care plans.
In addition, when members are supported in their health goals—even via a remote team or community—studies have shown reduced stress and better overall outcomes in individuals with chronic conditions like CKD. Dr. Joni Strom, MD, MPH at the Center for Health Disparities Research Medical University of South Carolina shares:
“With the rapid emergence of novel advances in technology, researchers must be mindful of the impact nontraditional neighborhoods, such as mobile texting groups, tablet applications comrades, and online communities, have in providing social support for individuals with T2D. Access to these modern-day ‘neighborhoods’ may create an environment more conducive for change and positive outcomes. These interactions may improve adherence, diminish socioeconomic and cultural barriers, and generate newfound resources for certain populations.”
Reducing member stress via digital health platforms that seek to support, not isolate, members through helpful reminders, incentives, and support teams can help members achieve a better quality of life through increased care plan adherence.
The NIDDK recommends getting 7 to 8 hours of sleep a night to reduce condition progression for those with CKD. However, the quality of sleep—not just the quantity of sleep—is important in achieving optimal health outcomes.
The Brigham and Women’s Hospital studied the connection between sleep disorders and kidney function, observing that individuals with sleep deprivation or sleep disorders were experiencing faster declines in their kidney functions. Dr. Ciaran McMullan, who is leading the study, explains:
“Kidney function is actually regulated by the sleep-wake cycle. It helps coordinate the kidneys’ workload over 24 hours... Nocturnal patterns can affect chronic kidney disease, and people who sleep less usually have faster kidney function decline.”
Still getting enough quality sleep is difficult. In a world of screens and technology, it can be hard to unplug and unwind at the end of the day—especially if we’ve had that late afternoon coffee—even when we want to sleep well. When sleep disorders enter the mix, achieving those 7 to 8 hours becomes even more difficult.
Digital health coupled with behavioral economics can help members improve both their quality and quantity of sleep by building the habits necessary for a better night’s rest. As the right behaviors are reinforced and strengthened, long-term habit formation follows.
Wellth’s digital health platform helps its members achieve better sleep quality, with proven results in improving adherence to care plans for members with sleep apnea and other sleep disorders.
For example, Wellth's “Restful” program worked with ResMed—a company offering medical devices designed to address respiratory issues like sleep apnea through machine and digital health products—to improve member sleep quality through behavioral economics. With the Wellth platform and Restful app, members achieved an average 36 minute increase in daily CPAP usage and an 84 percent adherence rate to prescribed sleep programs.
Smoking is the leading cause of preventable premature death worldwide—responsible for approximately 480,000 deaths in the U.S. alone each year. When it comes to individuals with CKD, smoking can interfere with medications taken for high blood pressure and lead to faster deterioration of kidney function.
Initial studies published in the New England Journal of Medicine have shown that incentive programs can help increase smoking cessation—achieving a 14 percent successful cessation rate versus 5 percent in the non-incentivized group. However, these numbers have room to improve.
Reframing incentive structures through behavioral economics has been shown to increase effectiveness of behavior change.
For example, in a study of at-risk students in a low-income area of Chicago, students who were borderline failing were paid $50 at the beginning of each month to stay in school and achieve at least a C grade in classes. As long as the students met the requirements, they could keep the money at the end of the month. In the second group, students received traditional incentives—where they could receive the $50 reward at completion of the month if they met the requirements.
Rather than lose the money, those students who received their money upfront worked harder to keep their reward (a principle known as loss aversion) than those who had to wait to receive their incentive. As a result, student achievement for the behavioral economics incentive structured group was 40 percent higher than the traditionally incentivized group.
Other studies have also highlighted the importance of a behavioral economics approach to incentive structures in healthcare—suggesting that the right framing can increase adherence to healthy choices by up to 70 percent. And the University of Pennsylvania is currently piloting a randomized control trial measuring the efficacy of behavioral economics-based incentive framing on improved smoking cessation.
The takeaway? Whatever you’re trying to help your member achieve, it’s not just what you offer, it’s how you offer it that will ultimately make a difference in impacting lasting change.
For more tips on leveraging behavioral economics and digital health to improve kidney health and better manage other patients with chronic conditions, subscribe to our monthly newsletter today.