ROCHESTER, MINN. — There's a lot of talk nowadays about hospitals' role in health — moving from a sick system to a wellness system. But at some point, patients need to take ownership of their well-being, too, to really start moving the needle.

That was one of the messages delivered Tuesday by David Katz, M.D., founding director of the Prevention Research Center at Yale University, during the final day of the Mayo Clinic's Transform 2014 conference. We can design gadgets with all sorts of bells and whistles to remind patients to exercise and eat healthfully, but eventually it's up to them to be responsible.

"Lifestyle is the best medicine and culture is the spoon. Now, isn't it interesting that in our culture, you have to pay people to care about being healthy?" Katz asked. "My response to that is: What the hell? Wait until you have money but your health is gone and see how you feel about that.

"We could keep incentivizing health," he said later, "but I think we also need to raise daughters and sons who aspire to be healthy."

Katz spoke of the need to create "sandbags" to stem the flood of unhealthy behaviors. So much of what shapes peoples' well-being happens in their day-to-day lives that the health care system can't fix it on its own. Sandbags must be created to disrupt behaviors.
One example: Create a tiered system in supermarkets for people in the government SNAP program. Their dollar would never be worth less, Katz emphasized, but it could be worth more if they choose to buy healthier items. There's already one such system out there, called NuVal, and as a success story, Katz cited a woman who lost 115 pounds just by shopping smarter with it.

"We need to acknowledge — humbly, of course; I'm a practicing physician — that health care really doesn't make health. Health is built from its foundations in the places people live and love and learn and work and pray and play," he said. "The places people really spend their time."

There was a lot of talk these past few days about building such sandbags into people's everyday patterns, rather than trying to force them into new and unfamiliar pathways. In another talk, Joseph Kvedar, M.D., director for connected health at Partners HealthCare, noted that individuals look at their smartphones about 100 times a day, on average. Why not insert health-related messages somewhere into that stream, reminding them to exercise or take their medication?

A couple of key elements are needed to make such an approach work, such as using "unpredictable rewards" to get patients using the app. Uber, the ride service, does something similar by randomly giving users a free ice cream coupon or discount on services for opening the program on their phone. Key, too, is deploying the "sentinel effect," with clinicians keeping an eye on the app's use. Patients are less likely to to stick with it if they know their doctor isn't paying attention.

Location services also could play a part, messaging a patient when he steps into a fast-food restaurant for lunch, suggesting a healthy alternative. Whatever the mix, Kvedar believes that, by pulling the right levers, the industry can get patients hooked.

"I do think we can make health addictive, and I think we need to make health addictive. We're not doing it right now," he said.