HEALTH CARE

port — and more support than whatan app can give you." He added thatconsumers need "the face-to-face[component] to supplement andwork in congruence with this tech-nology."

In a 2013 clinical study from theAmerican Journal of Medicine, usingresearch from both WeightWatchersand Baylor College of Medicine, theyfound that individuals who utilizedthe three core components of theirprogram — in-person meetings, mo-hile apps and online tools — had fargreater success losing weight.

The experiment followed par-ticipants in two main groups: thosewho strove to lose weight on theirown, and the other half that usedthe WeightWatchers program. Par-ticipants who used their programwere eight times more likely to havea clinically significant amount ofweight loss. Further, people whoregularly used all three componentslost 19 pounds on average, com-pared to those using one or two toolswho only lost 9 pounds on average."It shows the power of huilding asystem of supports," said Watts.

Quirky toolsThe CEO of StickK, an online

Wellness challenge platform, detailshow employers can form a "choicearchitecture" around Wellness in-centives to drive significant andlong-term hehavior change.

The StickK wehsite encouragesparticipants to set a goal that is oftenrelated to wellbeing such as quittingsmoking, running a 10k or losingweight, and assigns a family mem-ber or friend as a "referee" to keepthem honest.

"Then we ask that they put theirmoney where their mouth is," saysJordan Goldberg, StickK's CEO. Par-ticipants can set a wager with some-one, give money to a charity. Or theycan up the ante by forcing the loserto donate money to a cause theyparticularly revile, said Goldberg,if they don't accomplish their goal.There might be extra motivation ifa gun-control advocate didn't makethe cut and had to fork over moneyto the National Rifle Association;StickK can help facilitate that trans-action.

"To make a behavior change,you have to have skin in the game,"Goldberg explained. The "anti-char-ity" motivation is a great example, he

adds. "In a vacuum, a stick is morepowerful than a carrot. The threat oflosing $20 from your own pocket ismore motivating than gaining mon-ey you never had."

For employers, Goldberg recom-mends they incentivize employeesby putting the value of the rewardin context. An employee who earns$1,000 in cash for achieving a well-ness goal sees the reward in thecontext of their salary. For someonemaking $50,000 ayear, that's only 2%of their yearly earnings. However, ifthe employer presents the reward asa $1,000 vacation, viewed in contextof their vacation budget, that's sud-denly a more meaningful reward.

"Without anaggressive attackon the lifestyleissues that drivethe cost [of healthcare] we're notgoing to find asolution."

"And the perceived value is ac-tually greater when you use non-cash rewards," explained Goldberg.Those noncash rewards can be morepowerful because they provide a ref-erence point and remove the partic-ipant's guilt in indulging in a rewardby building an emotional connec-tion toward the incentive.

Enticing noncash rewards in-clude experiences that employeesnormally wouldn't buy for them-selves — from catered dinner par-ties to sports tickets — as well aspremier parking spots or lunch witha senior executive. Rewards for fam-ily outings, such as theme park tick-ets or private tutoring, are also greatexamples, as are services includinggym memberships.

"There are lots of tools you needto be aware of as a choice architectwhen you're designing an incentiveprogram," StickK's CEO emphasized.Here are some other suggestions fordeveloping meaningful rewards:

• Lottery-based rewards. Re-search shows that many peoplewould favor a one in 100 chance towin $200 over a guaranteed $2. Thisparticular study also found that

while 60% chose the lottery option towin cash, 80% would choose the lot-tery if the reward was a $200 gift cardto a nice restaurant. That emotionalconnection to the reward plays a rolein engaging participants.

• The power of defaults. Gold-berg suggests setting up Wellnessprograms and initiatives with anopt-out clause whenever possible,because people will accept the de-fault. This strategy has been usedsuccessfully in the retirement fieldto auto-enroll 401(k) participantsinto plans.

• Subliminal suggestion. Am-sterdam airport officials strategi-cally placed fake flies in the bowlsof urinals to encourage men to aimbetter. The result: cleaner floors.

• Progress illusion and loss aver-sion. A coffee company experiment-ed with their loyalty incentive byhanding out punchcards to custom-ers. On the card, customers receivedone free coffee if they bought eightcoffees. Then, the café gave custom-ers a similar punchcard requiringthe purchase of 10 coffees, but thefirst two were already punched. Thecustomer still needed to drink eightmore coffees to get their free cup,but people filled these cards 20%faster than the ones that weren't pre-punched.

Goldberg explains that even ifthey have to commit to the sameamount of work, if people feel they'restarting higher than zero, then theybelieve they have a head start andare more likely to engage. Instead ofstarting employee at zero as part ofa Wellness initiative to earn a mas-sage, give them some free points sothey don't feel like they are startingfrom scratch.

"At the end of the day with car-rots and sticks, it's all about fram-ing," Goldberg said.

On StickK, they frame the in-dividual's progress differently forfirst-timers than for return users.For a goal of weight loss, the first-time user sees how much weightthey've lost so far. But if the goal isfor a returning user who has hadsuccess in the past and returns tolose more weight, then they showhow many more pounds they needto lose to meet their goal. Partici-pants have different sets of expecta-tions, said Goldberg, and employersneed to design incentives based onthose disparate perspectives. •

MEDICAL TOURISM

The risksof goingabroad

BY JULIE MAUDA

Medical tourism is abooming industrydominated by Asiancountries, including

India, Thailand and Singapore. Indiaalone saw 2.5 million medical tour-ists in 2012, and one Thailand hospi-tal serves 400,000 patients annually.This trend shows no signs of abating.According to Transparency MarketResearch, in 2012 the global medi-cal tourism market was $10.5 billionand is estimated to reach $32.5 bil-lion by 2019. Scarcity of medical re-sources, improved communicationbetween countries, globalization ofhealth care, internet marketing andease of travel have also boosted theindustry.

As medical travel grows in popu-larity and expands to other coun-tries, U.S. employers need to be edu-cated on the ins and outs of tourismto ensure safety of their employeesand avoid fraud. It's also importantfor patients to do their own researchand be prepared to think about thedownsides of medical tourism.

Buyer bewareThroughout the Western world,

medical tourism may well offer alower-cost option for medical treat-ment without compromising onquality, but there are important con-siderations to research.

This starts with choosing thedestination. Whenever possible,travelers are advised to talk to theirlocal doctor first and find out whatquestions to research for their con-dition and who credentials thoseproviders abroad. Also consider thelanguage spoken where care wouldbe received. Research the country'srequirements on visas or proof ofability to pay before receiving treat-ment.

Patients should allow enoughtime in travel plans to receive thenecessary follow-up care — oftendays or weeks beyond the procedure.

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The treatment itself may be low-cost,but travel expenses also need to beadded. In addition, traveling post-surgery may increase complicationsand infectious disease standardsvary.

Upon return, there may be newcomplicating factors. In the most ex-treme cases, legal recourse for mal-practice claims or lawsuits may beminimal or nonexistent. In the worstcases of "botched" procedures, pa-tients may have to pay a U.S. surgeonto fix the original surgery.

Be aware of scamsFinally, employers need to be

aware of the scams. It's easier tofabricate services not rendered, dis-guise cosmetic services as medicallynecessary, inflate charges and mis-represent experimental or electivecare when everything is in a foreigncurrency, documented in a differ-ent language and care delivered8,000 miles away. It's less likely a U.S.claims payer would ever do an on-site billing audit.

Internet marketing has spawnedscam artists (i.e., alleged cures for

cancer), and medical travelers don'talways make informed decisions. Bewary of clinics not accepting insur-ance, customer service departmentslooking for advance or quick pay-ment, doctors overcharging patientsfor consultation or recommendingunnecessary procedures, and cor-ruption.

Claims administrators shouldlook for addresses that are really P.O.boxes or near aU.S. border; high-dol-lar member reimbursements beingrequested with no true proof of pay-ment; misuse of medical terminol-ogy; or a diagnosis that doesn't makesense for the length of stay.

Advanced analytics can play arole here in mining through text datato uncover medical documentationthat has been altered or collusiveschemes with organized crime thatcrosses country borders, but no ana-lytical method replaces doing yourhomework before the care is deliv-ered.

Do your homeworkEncourage employees consider-

ing medical travel to do research. Do

the homework, so as not to end up inthe headlines or with compromisedcare.

The medical travel industry willlikely get a boost from the growingnumber of Americans over the age of65 at risk of outliving their retirementfunds. With longer life expectancies,fewer company-provided pensionsand likely cutbacks in Medicare cov-erage, they will be seeking lower-cost alternatives for the latest medi-cal advancements.

While health care reform hasmade access to care in the U.S. morereadily available, the shortage ofdoctors, nurses and hospital bedsmay not meet increased demand.

Convention bureaus and market-ing partners promote destinationtravel based on the availability ofinexpensive procedures and accom-modations wrapped in a vacationpackage. But do they have the exper-tise to help make informed decisionswhen selecting a doctor or medicalfacility? It's up to the patients to dotheir own research.

Accrediting bodies such as theJoint Commission International

— the international arm of the orga-nization that reviews and accreditsAmerican hospitals — send teamsto accredit/re-accredit hospitalsevery three years. Sadly, though, asof this writing, only 634 hospitalsworldwide had been accredited. InMexico, only seven facilities met thestandards, yet Mexico is a popularmedical tourist destination, likelydue to its close proximity to the U.S.and abundance of vacation spots. Apotential medical traveler shouldalso contact the destination's gov-ernment health authority websitesand check licensure.

At the end of the day, only em-ployees who do the appropriate re-search can make the most informeddecisions and have the best chanceat a good outcome at the lower costthey desire.

Caveat emptor. •

Julie Malida is the principal for healthcare fraud solutions in the security in-telligence practice at the SAS InstituteInc. She is a Fellow of the Society ofActuaries and a Member of the Amer-ican Academy of Actuaries.

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