Welcome to the 2022 Annual Report of the Penn Center for Health Incentives and Behavioral Economics (CHIBE). It has been quite a year.
This was our 14th year, and we have gone from a handful of individuals using principles of economics and psychology to develop and test interventions to improve health behavior to an entity with more than 90 affiliated faculty working to understand and improve the health of individuals and the value of health care services provided in the United States and abroad.
In this report you’ll learn about our team’s work in areas including increasing COVID-19 vaccine uptake, reducing unnecessary opioid prescribing, increasing hepatitis C screenings in hospitalized patients, helping to boost postpartum individuals’ daily step counts, and creating the first nudge unit in South Africa—the country with the world’s highest rate of HIV infections. You’ll also see how CHIBE faculty and the Way to Health team made an impact this year, including through the creation of COVID Watch, an automated text messaging service. This program has provided escalating support as needed for more than 30,000 COVID patients and was found to reduce mortality rates by 68%, garnering Article-of-the-Year awards from both AcademyHealth and the Annals of Internal Medicine.
In July of 2021, the portion of our research that promotes healthy behaviors and my research on reducing the risk of cardiovascular disease became even more meaningful. Out of the blue I had a heart attack. It was a surprise since I had been training for a 70.3 Ironman with one of my daughters, felt great, and was in the best shape I had been in since age 25. Fortunately, due to the prompt activation of EMS, initiation of CPR by my daughter’s coaches Gina Stoker and John White, and the skillful interventions of the Cincinnati EMS team and the nurses and doctors at the University of Cincinnati Medical Center, I survived and walked out of the hospital five days later. Many of my doctors and nurses said I wouldn’t have survived if I hadn’t been in such good physical shape. This left me with new appreciation for the serendipity of life and the importance of us each trying to lower our risk of significant health events as much as we can. The combination of this personal close encounter with the health system and recognition that cardiovascular disease remains the leading cause of death in the United States and many other countries led me to redouble our team’s efforts to systematically develop ways to reduce the risk of heart disease using analytics and behavioral science.
In all of our efforts, we seek opportunities to advance the science of behavior change to improve health and advance health equity worldwide. We thank you for your continued support, interest, and contributions.
Kevin Volpp, MD, PhD
Mark V. Pauly President’s Distinguished Professor
Perelman School of Medicine and the Wharton School
University of Pennsylvania
Thank you to Hoag Levins, Editor of Digital Publications at the Leonard Davis Institute of Health Economics, as well as photographers Daniel Burke and Eric Sucar for the photos contained in this report.
About Our Center
CHIBE is the leading scientific organization using behavioral economics to improve health. Drawing on the expertise of faculty from across the University of Pennsylvania and beyond, CHIBE conducts behavioral economics research aimed at reducing the burden of disease from major public health challenges and seeks to advance health equity worldwide.
Our mission is to advance the science of applied behavioral economics in pursuit of knowledge, interventions, and policies that lead to higher-value health care, equal access to health care, and healthier lives for all.
CHIBE, which was originally founded within Penn’s Leonard Davis Institute of Health Economics (LDI), is one of two original NIH-funded Roybal Centers in Behavioral Economics and Health in the United States. Today, we continue to be part of the robust network of 15 Roybal Centers across the United States, which focuses on the development of interventions to support healthy aging. Since our founding, our Center has specialized in research and dissemination strategies that support the translation of behavioral economic theories to improve health behaviors and health care delivery. We work with public and private sector organizations locally, nationally, and globally that share our passion for improving people’s lives.
We have successfully conducted many observational studies and randomized trials using principles of behavioral economics to improve health in a wide variety of clinical, employer, and health plan contexts that have resulted in programs benefiting tens of millions of patients.
Our Four Pillars of Research
Our investigators conduct research to understand the behavioral factors that influence food choice, medication adherence, physical activity, and smoking cessation, among other behaviors.
DIGITAL HEALTH & WEARABLES
Our team applies principles of behavioral economics to connected health through interventions that leverage CHIBE’s Way to Health software platform, as well as wearable fitness trackers and apps.
HEALTH CARE DELIVERY
CHIBE explores innovative behavioral economic solutions to improve health outcomes while reducing costs through the transformation of health care delivery.
HEALTH POLICY & FINANCING
Our researchers examine the impact of policy initiatives and shifts in health incentives on patient, clinician, and health system outcomes through a mixture of observational studies and experimental work.
CHIBE at a Glance
A healthier and more equitable world powered by behavioral economics
Top Tweets from @PennCHIBE
Congrats to CHIBE Associate Director @Rsbeidas who has won the Research Pioneer Award from @Acenda_AIHI! This award is part of AIHI’s inaugural “Momentum Awards,” which celebrate people paving the way for the future of behavioral health care delivery.
What did we learn from the Philly Vax Sweepstakes, which aimed to increase COVID-19 vaccinations? Read our Q&A with @LinneaGandhi, who recently led the evaluation of its impact.
Some health experts believe communities should set up public vaccination clinics for kids instead of relying on individual pediatricians. “The more visible we make this process, the more trust we’ll see across the communities,” said @CarolynCannu. Read the article here.
Congrats to @abuttenheim and @kevin_volpp, who are serving on @theNASEM’s new consensus committee on future directions for applying behavioral economics to policy. Read more.
Research and News Highlights
Dr. Harsha Thirumurthy spoke with CBS News about a study he led on the association between statewide financial incentive programs and COVID-19 vaccination rates. “We compared 24 states that did have vaccine incentive programs to 26 states that didn’t have vaccine incentive programs. What we found is that there was no effect on the daily vaccination rates, which means we did not see more people coming in to get vaccinated in the immediate aftermath of these statewide incentives.”
This study of 7,600 patients explored the difference between using a default order or a conventional alert in the electronic health record (EHR) to increase hepatitis C virus (HCV) screening in the hospital setting. With this minimal incremental cost intervention that potentially saved clinicians’ time by reducing clicks in the EHR, the researchers discovered the default order doubled the rate of hepatitis C screenings among patients for whom they were recommended (from 42% to approximately 80%). “The intervention shifted HCV screening from opt-in to opt-out. For most screening tests, the default is not to order the test, and it requires decision-making to actively choose the test. In this case, the default was that HCV screening was going to be ordered, and it required the clinician to actively click the order to opt out,” the study authors noted.
Authors: Shivan J. Mehta, MD, MBA, MSHP; Jessie Torgersen, MD, MHS, MSCE; Dylan S. Small, PhD; Colleen P. Mallozzi, MBA, RN; John D. McGreevey III, MD; Charles A.L. Rareshide, MS; Chalanda N. Evans, MPH; Mika Epps, RN, MSN; David Stabile, RN, MSN; Christopher K. Snider, MPH; Mitesh S. Patel, MD, MBA
This study explored whether behavioral economics tools such as gamification and social incentives could improve physical activity among postpartum individuals with hypertensive disorders of pregnancy. All participants received wearable devices and a step goal, but those in the intervention arm were also placed on virtual teams and participated in games that encouraged them to achieve their step goal. Compared with the control arm, the individuals participating in the intervention had a greater increase in mean daily steps from baseline – nearly 650 more steps.
Authors: Jennifer Lewey, MD, MPH; Samantha Murphy, BA; Dazheng Zhang, MS; Mary E. Putt, PhD, ScD; Michal A. Elovitz, MD; Valerie Riis, MS; Mitesh S. Patel, MD, MBA; Lisa D. Levine, MD, MSCE
Dr. Carolyn Cannuscio spoke with The Washington Post about the social etiquette of disclosing symptoms before gathering with friends or family. She said some people may stay home instead of socializing because of what she calls “anticipatory regret,” meaning they would regret the decision to go out if they ended up getting friends or family sick with COVID-19. “I think of sharing or disclosing health information as part of the social contract now,” Dr. Cannuscio told The Washington Post. “It’s one of the few tools we can use to try to protect one another.”
CHIBE in the Media
”I conducted a study of guaranteed small financial incentives for COVID-19 vaccination and found that the incentives slowed the decline in vaccination and promoted more equitable distribution by alleviating barriers to vaccination, particularly for low-income, Black, and Hispanic individuals.Charlene Wong, MD, MSHP
”We conducted a series of experiments to explore whether individuals optimally value tools that make things cognitively easier, like reminders to complete a future task.Judd Kessler, PhD, MPhil
”We did a qualitative analysis of our clinical trials’ participants to uncover that socioeconomic background and challenging living conditions are an important barrier to responding to incentives for statin medication adherence to reduce the risk of atherosclerotic cardiovascular disease.Iwan Barankay, PhD
What behavioral science project did you work on this year?
”We are conducting a 3-site trial that tests gamification strategies to improve cardiovascular outcomes in Black and Hispanic breast and prostate cancer survivors.Laurie Norton, MA, MBE
”Across six pre-registered studies, we introduce a measure of exponential numeracy — the ability to understand exponential growth — and we show that individuals higher in exponential numeracy can give more accurate forecasts of exponential phenomena, including the spread of COVID-19. The paper shows that people low in exponential numeracy may be engaging in a behavioral economics bias called anchoring-and-insufficient-adjustment.Eric VanEpps, PhD
”We conducted a randomized controlled experiment of physicians' decision-making, which demonstrated how changes to clinicians' peer networks eliminated patterns of race and gender bias in their treatment recommendations for white male and Black female patients.Damon Centola, PhD
”In our trial evaluating feedback interventions (usual care, peer comparison, audit feedback, audit and peer comparison) to reduce opioid prescribing in the emergency department and urgent care settings, we observed a significant and sustained decrease in pills per prescription both for peer comparison feedback and for the combination of peer comparison and individual audit feedback arms, relative to usual care.David Pagnotti, MS
”I analyzed data from two randomized controlled trials aimed at testing the effectiveness of behavioral nudges in increasing the take-up of COVID-19 vaccinations and found that reminders designed to make vaccination salient and easy increased the take-up of vaccinations up to 4 weeks after the intervention; the effects were substantially larger among individuals with a prior history of influenza vaccination.Silvia Saccardo, PhD
”Our team performed a quasi-experimental study of a voucher incentive program aimed at improving COVID vaccine uptake among older South Africans.Lizzie Bair, MS
“COVID Watch” Saved Lives During COVID Surge
A paper led by CHIBE Associate Director Dr. M. Kit Delgado evaluated the effectiveness of an automated text messaging service for monitoring patients sick at home with COVID-19. This service, called COVID Watch, delivered twice-daily texts to patients to check to see how they were feeling and if they had any trouble breathing. Patients could also report worsening symptoms, which would be handled by telemedicine clinicians 24 hours a day. In this study, which looked at patients who tested positive for COVID between March 23 and November 30, 2020, the researchers discovered patients enrolled in the system were 68% percent less likely to die than those not using it. There were 1.8 fewer deaths per 1,000 patients at 30 days among enrolled COVID Watch patients and 2.5 fewer deaths per 1,000 patients at 60 days. This paper won the Publication-of-the-Year Award from AcademyHealth and was named “Best of 2021” by Annals of Internal Medicine. COVID Watch was built on Penn’s Way to Health platform.
Researchers Study Health Effects of Investment in Black Neighborhoods
A research team led by CHIBE-affiliated faculty members and principal investigators Drs. Eugenia South and Atheendar Venkataramani was awarded nearly $10 million from the National Institutes of Health to conduct a randomized controlled trial of concentrated investment in Black neighborhoods in Philadelphia to address structural racism as a fundamental cause of poor health. The team will implement several place-based interventions proven to improve health, including vacant lot greening, abandoned house remediation, tree planting, and trash cleanup. They will also partner with community-based financial empowerment providers to build cross-organizational communications and data infrastructure to increase Black residents’ access to financial services and public benefits. In addition, they will connect Black households to partners to apply for and receive key health-promoting public benefits (such as utilities assistance and food benefits), tax preparation and financial counseling services, and emergency microgrants.
Intervention Boosts HIV Testing Uptake in South Africa
In partnership with researchers from the Desmond Tutu Health Foundation (DTHF) in South Africa, CHIBE’s Scientific Director Dr. Alison Buttenheim and Associate Director Dr. Harsha Thirumurthy designed and trialed a “U=U” (Undetectable = Untransmittable) intervention to encourage HIV testing among men in South Africa. U=U messaging applies behavioral insights to amplify the benefits and effectiveness of HIV treatment; in this study, the U=U message nearly doubled the proportion of men who responded to an invitation to take an HIV test. Dr. Buttenheim and DTHF colleague Dr. Andrew Medina-Marino were recently awarded an R01 grant from the National Institutes of Health to test this approach at scale in South Africa. Based on these results and others, the Eastern Cape province of South Africa recently announced a public information campaign to raise awareness of U=U and to encourage individuals to engage in HIV testing and treatment. Watch an animated video on the left that was created to describe the study results.
CHIBE Leadership Named to Behavioral Economics-Focused NASEM Committee
The National Academies of Sciences, Engineering, and Medicine (NASEM) consensus committee on “future directions for applying behavioral economics to policy” appointed CHIBE’s Scientific Director Dr. Alison Buttenheim as a co-chair and CHIBE Director Dr. Kevin Volpp as a committee member.
The committee seeks to review insights from behavioral economics to see how they could be leveraged in public policy objectives related to issues ranging from improving health, increasing retirement savings, and addressing climate change. The members will create a report that will ideally inform funding strategies, research priorities, and evidence synthesis and dissemination for the next 5-10 years.
Our Signature Events
This year CHIBE held its 10th annual Behavioral Science and Health Symposium, which brings together leading academics to discuss cutting-edge research in health-applied behavioral economics and goals for advancing the field forward. This year, CHIBE welcomed Drs. Dean Karlan from Northwestern and Carol Dweck from Stanford as our keynote speakers.
Each year, our Center also holds a Roybal Retreat for CHIBE faculty, trainees, and staff. In FY22, we held our retreat in collaboration with our sister Roybal Center at Penn, the Palliative and Advanced Illness Research (PAIR) Center. Penn is the only university in the country with two National Institute on Aging Roybal Centers. In addition to research presentations and team-building exercises, the retreat featured a workshop led by Dr. Sylk Sotto on tools for responding to racism, discrimination, and microaggressions.
CHIBE also hosted a special webinar moderated by CHIBE Associate Director Dr. Amol Navathe in March 2022 with panelists from the University of Pennsylvania and Humana to discuss how health care is evolving and how we might optimize the value of care received to improve patient outcomes, address health equity concerns, and make care more affordable.
Penn Medicine Nudge Unit
Launched with support from CHIBE and the Penn Medicine Center for Health Care Innovation, the Penn Medicine Nudge Unit is the world’s first behavioral design team embedded within the operations of a health system. The Nudge Unit was led this year by Dr. Rinad Beidas with Deputy Directors Drs. Srinath Adusumalli and M. Kit Delgado. The team’s mission is to leverage insights from behavioral economics and psychology to design and test approaches to steer medical decision-making and daily health behaviors toward higher value and improved patient outcomes. Since launching in 2016, the team has worked on more than 100 projects including nudging clinicians and patients, predicting decision-making and health behaviors, and behavioral phenotyping. Many of these projects have been scaled either throughout Penn Medicine or implemented in other health systems. The Nudge Unit’s work has been published in leading medical journals including NEJM, JAMA, and the Annals of Internal Medicine. It has also been featured in a wide range of media outlets including The New York Times, Wall Street Journal, Economist, Harvard Business Review, and Freakonomics.
PSYCHOLOGY OF EATING AND CONSUMER HEALTH (PEACH) LAB
The mission of the Psychology of Eating and Consumer Health (PEACH) Lab, directed by CHIBE Associate Director Dr. Christina Roberto, is to identify and evaluate innovative policies and interventions to promote healthy eating habits and prevent nutrition-related chronic diseases. The Lab focuses on studying relationships between the social and commercial determinants of health and evaluating policies that will lead to structural changes to support healthy eating habits, particularly among low-income and racial and ethnic minority groups most impacted by diet-related diseases.
This past year, the Lab continued to contribute to the scientific evidence base supporting the use of sugary drink taxes to discourage consumption of unhealthy beverages and raise revenue to be invested into marginalized communities. They published a paper demonstrating that the Philadelphia sweetened beverage tax led to a 35% reduction in taxed beverage sales two years later with no evidence of substitution to high sugar foods. The Lab also published a randomized controlled trial of a Hispanic-targeted sugary drink countermarketing campaign designed to make parents aware of misleading marketing on fruit drinks. The campaign was delivered via social media and reduced Hispanic parents’ selection of fruit drinks and their children’s intake. The Lab is also developing a new line of research on water insecurity in Philadelphia to inform City policy. In recognition of the Lab’s rigorous research and impact, Dr. Roberto was named a National Academy of Medicine Emerging Leader.
THE FIELDS PROGRAM
Directed by Dr. Scott Halpern, the Fostering Improvement in End-of-Life Decision Science (FIELDS) program is the world’s first program dedicated to using principles of behavioral economics to understand and improve upon the end-of-life decisions made by patients, caregivers, and clinicians. It sits jointly within the Palliative and Advanced Illness Research (PAIR) Center and CHIBE. The mechanistic insights into end-of-life decision making generated by the FIELDS Program often provide the “basic science” upon which scalable interventions tested by the PAIR Center are built.
Accelerate Health Equity
Accelerate Health Equity (AHE), directed at Penn Medicine by Drs. Kevin Volpp, Raina Merchant, and Erica Dixon, is a collaboration with Independence Blue Cross and health systems across Philadelphia, including AmeriHealth Caritas, Children’s Hospital of Philadelphia, the City of Philadelphia, Drexel University, Independence Blue Cross, Jefferson Health, Main Line Health, Philadelphia College of Osteopathic Medicine, Temple Health, and Trinity Mid-Atlantic, all “working together for a healthier Philadelphia.”
AHE is a multi-year initiative principally funded by Independence Blue Cross with a goal to combat systemic racism and health disparities, with three core components, including launching and evaluating pilot programs intended to impact health outcomes, measuring progress toward achieving health equity through an online dashboard, and collaborating to scale successful pilots across the city. The initial focus areas of AHE are maternal health, mental health, cardiovascular health, and colorectal cancer.
WAY TO HEALTH
Way to Health is an integrated, cloud-based platform that blends behavioral science with scalable digital technology to conduct randomized controlled trials of healthy behavior interventions and strategic telehealth programs. Operated as a partnership between CHIBE and the Penn Medicine Center for Health Care Innovation, the platform provides both remote monitoring and engagement solutions as well as tools for developing and deploying new interventions. The platform has supported close to 300 clinical and research projects that focus on facilitating improvements in a wide range of clinical contexts including blood pressure, medication adherence, weight loss, physical activity, and more.
During FY22, the Way to Health team implemented 51 projects over 52 weeks – essentially close to a project per week. Ongoing projects continue to grow. has now managed close to 32,000 patients; while there have been multiple publications based on this initiative, of note this work received article-of-the-year citations from both the Annals of Internal Medicine and AcademyHealth. The Way to Health team has now reached close to 1.5 million individuals in various health improvement efforts.
CHIBE Associate Director Dr. Harsha Thirumurthy and CHIBE Scientific Director Dr. Alison Buttenheim continue to lead a first-of-its kind HIV nudge unit in South Africa called Indlela (which means “the way” or “the path” in Zulu), funded by the Bill & Melinda Gates Foundation. Now in its third year, Indlela is working closely with researchers at Wits University to build local capacity to do applied behavioral economics research. Indlela is also collaborating with numerous organizations that deliver HIV services in the public sector. In Behavioral Insights Tests that are being supported by Indlela, researchers are applying behavioral science principles to increase utilization of HIV services. These rapid evaluations of nudges and other behavioral interventions to improve HIV prevention and treatment outcomes are ultimately seeking to identify innovative ways to end the world’s largest HIV epidemic.
PAYMENT INSIGHTS TEAM
Led by CHIBE Associate Director Dr. Amol Navathe, the Payment Insights Team is an interdisciplinary team of experts based in the Perelman School of Medicine whose mission is to utilize insights from economics and behavioral science to analyze existing policy effects and design, test, and evaluate financial and nonfinancial interventions that can improve health care in pragmatic, real-world settings. The Payment Insights Team is committed to doing so in collaboration with health insurer, health system, physician practice, and policymaker partners in order to achieve organizational and societal goals of greater health care value and equity.
Current projects within the Payment Insight Team’s portfolio focus on bundled payments, large-scale redesign of physician and hospital payment models, optimal use of nudges in health care, and design of predictive models to drive behavior change. The Payment Insight Team’s work has been featured in JAMA, Science, Health Affairs, Journal of Hospital Medicine, Annals of Internal Medicine, The New York Times, as well as in many other high-profile and impactful, scientific journals and media outlets.
THE BEHAVIORAL SCIENCE & ANALYTICS FOR INJURY REDUCTION (BESAFIR) LAB
CHIBE Associate Director Dr. M. Kit Delgado, Assistant Professor of Emergency Medicine and Epidemiology and a practicing trauma center emergency physician, leads the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) Lab, which applies data and behavioral science to improve acute care and to prevent injuries and overdoses. This includes analyzing emergency department and hospital encounter data and leveraging electronic health records, text-messaging, and other digital interventions to change clinician and patient behavior. Recent successes include identifying effective strategies for: 1) managing COVID-19 at home; 2) increasing disposal of unused opioid pills; and 3) increasing emergency department evidence-based treatment for opioid use disorder. BeSAFIR’s work is currently funded by PCORI, CDC, FDA, and NIH.
Joint Research Practices
The Joint Research Practices (JRP) is chartered by the leadership at CHIBE and the Palliative and Advanced Illness Research (PAIR) Center to develop and disseminate best practices and guidelines for the conduct of inclusive and anti-racist research that advances the science and practice of health equity. Its work is evidence-based, community-informed, and programmatically focused with the aim of building digital resources and codes of conduct detailing best practices for carrying out research at the two centers. The guidelines will reflect best practices in: research team structure and composition; engagement with under-represented, underserved communities; participant eligibility, representativeness, recruitment, retention, and use of incentives; measurement and reporting of patient characteristics including race and ethnicity; and dissemination of results. CHIBE Associate Director Jingsan Zhu, MS, MBA, and Rachel Kohn, MD, MSCE, a PAIR core faculty member, co-chair the JRP.
Awards and Recognition
Research Pioneer Award
Rinad Beidas, PhD
Gustav O. Lienhard Award for Advancement of Health Care
Risa Lavizzo-Mourey, MD, MBA
Christian R. and Mary F. Lindback Foundation Award for Distinguished Teaching
Katy Milkman, PhD
Samuel Martin Health Evaluation Sciences Research Award
Raina Merchant, MD, MSHP, FAHA
Early Investigator Award
Eugenia South, MD, MSPH
Duncan Van Dusen Professionalism Award for Faculty
Carmen E. Guerra, MD, MSCE, FACP
2021 Leader in Health Care
Kevin Mahoney, MBA
* For “Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home” published in February 2022 in Annals of Internal Medicine. Full author list: M. Kit Delgado, MD, MS, Anna U. Morgan, MD, MSc, MSHP, David A. Asch, MD, MBA, Ruiying Xiong, MS, Austin S. Kilaru, MD, MSHP, Kathleen C. Lee, MD, David Do, MD, Ari B. Friedman, MD, PhD, Zachary F. Meisel, MD, MPH, MSHP, Christopher K. Snider, MPH, Doreen Lam, BA, Andrew Parambath, BA, Christian Wood, BA, Chidinma M. Wilson, BA, BS, Michael Perez, BS, BA, Deena L. Chisholm, MPH, Sheila Kelly, MPH, Christina J. O’Malley, MHA, Nancy Mannion, DNP, RN, CEN, Ann Marie Huffenberger, DBA, RN, NEA-BC, Susan McGinley, CRNP, Mohan Balachandran, MA, MS, Neda Khan, BS, Nandita Mitra, PhD, and Krisda H. Chaiyachati, MD, MPH, MSHP
CHIBE receives project-specific funding from foundation, corporate, and federal sponsors. Diversification of our portfolio has been a strategic priority over the past several years, and we have been successful in securing funding from several commercial entities and foundations. In addition, CHIBE receives support from the University of Pennsylvania Health System and the Perelman School of Medicine that has enabled us to make strategic investments, strengthen our
infrastructure, and support junior faculty and trainees. We are also grateful to the Otto Haas Charitable Trust, whose gifts allow us to continue strengthening the infrastructure of Way to Health, making it more accessible to junior faculty and trainees by increasing the ease of use and reducing the cost. Generous support from the Otto Haas Charitable Trust has also allowed us to continue to contribute to CHIBE’s permanent endowment fund. This year also marked a gift from Independence Blue Cross to support the regional health equity initiative. In addition, we received a generous gift from an anonymous donor for a Director’s innovation fund for the support of high priority, quick-turnaround initiatives.