Digital Health Is Not a Hammer: Why Your Interventions May Be Set Up for Failure

As more data has become available on the success of digital health and wellness platforms, it’s become clear that many health plans and self-insured employers don’t have the positive return on investment (ROI) they’d hoped to see. A 2013 study by RAND  Health (which did not focus exclusively on digital interventions) finds that employers have an overall ROI for health and wellness interventions of $1.50 per employee, but that disease management programs drive much of it. Wellness programs deliver, on average, only about a $0.50 ROI. It’s not nothing, but it’s also not enough to pin all of our hopes on. Is it time to give up on digital health?

I don’t think so–I think the ways in which most organizations roll out and incentivize these programs plays a role in diluting their efficacy. For example:

Most organizations require or encourage all members of their population to participate. While one of the beautiful things about a digital intervention is the ability to personalize it for each user (at least to some extent), the fact is that no intervention will be the right fit for every single person. Some people might hate digital. Some people might distrust digital (I have seen a lot of this in my career, and it’s exacerbated as soon as there’s an employer or health plan involved). Some people may be outside the boundaries of what the intervention can personalize for–think someone who’s seriously chronically ill, or someone who’s unusually healthy and fitness-focused.

A better solution, I think, is to make the digital health programs one of several options for population members. Offer a mix of digital, in-person, and group-based interventions and let people choose (or guide them so that the higher cost interventions are judiciously assigned to the people who need them most). If you can tolerate it, structure your participation framework to let people opt out entirely, since a disengaged user isn’t likely to provide the results you want anyway. The RAND research supports the idea that having fewer people participating in the wellness programs in particular is unlikely to significantly affect costs. By including the entire population in an intervention and measuring ROI across that group, you add a lot of noise to the data and obscure the positive effects some people do have.

From RAND (https://www.rand.org/content/dam/rand/pubs/research_briefs/RB9700/RB9744/RAND_RB9744.pdf); Wellness programs see the most participation but provide the least ROI
Wellness programs see the most participation but provide the least ROI; from RAND (https://www.rand.org/content/dam/rand/pubs/research_briefs/RB9700/RB9744/RAND_RB9744.pdf)

And some programs do have positive effects for some people! Consider this recent Wall Street Journal article on digital interventions for depression, which cites several peer-reviewed articles testifying to the efficacy of digital interventions to reduce symptoms of depression and anxiety. There are many other documented examples where people were able to achieve health goals using digital interventions. They can work.

The most common incentive structures do not motivate real behavior change. Extrinsic incentives tend to zap interest over time, and they are usually assigned to behaviors that don’t drive real change. Why, then, do so many employers and health plans that offer digital health interventions apply some form of financial incentive to participating? Worse, why are these incentives often too good to pass up? The result is a large population of people who are completing a digital program “on paper” to earn their incentive without seriously committing to the desired behavior change. I believe that rethinking the incentive structure is a necessary step to improving the ROI of digital health and wellness programs, even though it will almost certainly reduce overall participation in them.

Few digital health interventions have achieved the right mix of sound science and sexy design. This is changing in the last few years, but for the longest time, it seemed like you had to either choose a solid scientific base or a beautiful, engaging design. Unfortunately, the former makes it more difficult to hold users’ attention (and win clients), while the latter is less likely to bring about meaningful results. (It’s worth mentioning that some programs do poorly on both sides of the equation, causing me to wonder: why?)

My concern is that as long as buyers of these programs focus on traditional engagement metrics like clicks and registrations as a key success indicator, the more vendors will focus on design to the detriment of science. An optimal program  will be easy to use, lovely to look at, and leverage principles of health science and behavior change.

Back when I worked for HealthMedia (later Wellness & Prevention), we talked about digital health across a variety of categories including wellness and disease management.
Back when I worked for HealthMedia (later Wellness & Prevention), we talked about digital health across a variety of categories including wellness and disease management.

Digital health is not a hammer, and your population is not nails. While you may choose to administer certain programs to your entire population–like a health risk assessment (HRA) as a data-gathering exercise–I can’t think of any behavior change interventions that are universally effective. People are different from one another and different across their life span. Even a highly personalized digital program won’t work for 100% of people (nor, for that matter, will the very best live coach). If digital health is the only tool in your toolkit, then there will be some jobs you won’t get done.

What I hope to see in the next few years to help digital health live into its promise is a combination of factors:

  • Users are given more guided options about how to approach their health and wellness goals, with digital being included in the mix. If moving to a fully high-touch option is cost-prohibitive, consider programs that augment digital interventions with human coaching, as these often have positive results
  • Incentives structures are recalibrated to de-emphasize financial incentives and favor health-supportive rewards or voluntary participation. Based on some of my past experience, I would also recommend enlisting physicians as digital health champions; many people are more likely to try something if their doctor gives it the thumbs-up
  • Program designers include a strong mix of design skills, including science, on their teams so that products balance an evidence base with an engaging experience

I believe that if these things were to happen, we’d see more encouraging data about the efficacy of digital health.

2 thoughts on “Digital Health Is Not a Hammer: Why Your Interventions May Be Set Up for Failure”

  1. Thanks Amy for a great article. At Solera Health we agree completely and have created a network of digital AND community partners as a preventive care benefits manager. One size does not fit all and consumer choice drives engagement and outcomes.

    1. Thanks, Brenda! I’ll definitely check you guys out, but I love the sound of combining digital and community resources to help fit people’s needs.

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