Overcoming the challenge of getting people to maintain beneficial lifestyle changes for a long time

In Series 2 Episode 10 of the Health Points podcast Ben and Pete welcome Scott Taylor of Perx Health. Scott discusses his background in behavioral economics and how it led him to co-found Perx Health. He explains the concept of gamification in healthcare and the use of behavioral science principles through gamification to promote positive health behaviors. The conversation revolves around personalization, motivation, habit formation, and long-term engagement in managing chronic conditions. Scott shares statistics on Perx’ user engagement and retention rates compared to other digital health services. He also highlights the importance of rewarding effort, setting clear goals, and positively reinforcing small steps towards behavior change rather than solely focusing on end goals. The episode concludes with discussions on research conducted by Perx Health validating their impact on patient adherence and clinical outcomes. They also discuss the business model of working with large health plans and insurers to deliver programs for patients managing multiple chronic conditions.

You can listen to this episode below:

Outline:

Chapter 1: Introduction, Timestamp: 00:06-00:15Overview of the Health Points show and introduction of the hosts, Ben and Pete.Chapter 2: Guest Introduction, Timestamp: 00:27-00:46Introduction of the guest, Scott, with his academic background in behavioral economics and his interest in applying it to motivation and positive health behavior.Chapter 3: Background and Motivation, Timestamp: 02:25-03:10Discussion on the challenges of getting people to review their lifestyle, develop beneficial habits, and maintain them for extended periods.Chapter 4: Co-Founders and Team Building, Timestamp: 03:10-03:53Scott shares how he met his co-founder, Hugo, and how they decided to bring their ideas to the healthcare industry.Chapter 5: Incorporating Behavioral Economics and Gamification, Timestamp: 06:13-07:48Scott discusses the process of merging behavioral economics and gamification principles into their app and product.Chapter 6: Engaging with Perks Health’s Platform, Timestamp: 07:48-10:08Explanation of how users interact with Perx Health’s platform, including setting up treatment plans, participating in challenges, and engaging with game features.Chapter 7: Personalized Motivation and Gamification, Timestamp: 11:21-14:41Discussion on the importance of personalizing motivation in the app, tailoring notifications to resonate with users’ previous positive actions, and making engagement salient.Chapter 8: Long-Term Engagement and Behavior Change, Timestamp: 15:52-17:28Exploration of the need for long-term engagement in driving behavior change and the challenges faced in retaining users in digital health solutions.Chapter 9: Perx Health’s Engagement and Retention Statistics, Timestamp: 18:32-19:44Scott shares statistics on Perx Health’s engagement and retention rates, comparing them to other behavioral health apps.Chapter 10: Dynamic Adjustment of Mechanics and Gamified Features, Timestamp: 20:41-22:39Discussion on the ongoing adjustment and change of gamified features to create and reinforce behavior change.Chapter 11: Reinforcing Meaningful Purpose and Clear Expectations, Timestamp: 29:27-31:53Importance of reinforcing the meaningful purpose of health behaviors and setting clear expectations and goals for users.Chapter 12: Capturing Information and Showing Progress, Timestamp: 33:29-35:43Explanation of how Perx Health captures user data and displays progress in the app to remind and motivate users.Chapter 13: Research and Clinical Studies, Timestamp: 35:48-37:11Discussion on the research conducted by Perx Health, including a clinical study on the impact of the app on patients managing chronic conditions.Chapter 14: Operating and Working in the US Market, Timestamp: 40:33-42:21Scott talks about Perx Health’s focus on operating and growing in the US market.Chapter 15: Tailoring Programs and Personalized Engagement, Timestamp: 45:19-46:11Discussion on the personalized approach to long-term engagement and the potential duration of programs offered by Perx Health.Chapter 16: User Feedback and Experience, Timestamp: 47:59-49:18Importance of gathering user feedback and understanding their experience with Perx Health.Chapter 17: Conclusion, Timestamp: 49:18-50:03Recap of the discussion and appreciation for Scott’s insights and participation in the show.

Episode Transcript:

Ben
Hey everyone, and welcome to another episode of Health Points where we talk about anything and everything, gamification and health. I’m Ben and here with me today is my co host, Pete.

Pete
Hi everyone, looking forward to another episode.

Ben
And joining us today we have Scott, one of the co founders of Perx Health. Scott has an academic background in behavioral economics with real world interests in his application to motivation and positive health behaviour. He has a background in private equity investment in consumer, industrial and technology companies before he started Perx health. Scott, it’s great to have you on the show today.

Scott
Thanks for having me, Ben. Great to meet you, Ben.

Ben
Right, let’s start diving into your background. It’s quite a mixed background. And then what led you then to co founding Perx Health?

Scott
Yeah, no worries at all, as you say. I think probably the origins of kind of me becoming interested in gamification and health and then ultimately founding Perx was some of the work I did in university days studying behavioral economics and experimental economics. And that led down a path, I think I was very interested in the topic, couldn’t really figure out how there was a career in behavioral economics and experimental economics and then so went into finance. My degree was in economics and finance and was working and investing in effectively consumer technology and industrial companies.

Scott
And actually as I kind of worked with more and more tech companies and saw later stage tech companies that were making investments in and the way that they built their products, realized that actually some of the best behavioral sides, the best behavioral economics principles were being embedded in these products. And I think that really led to me thinking about is there actually a way that we can take some of the magic they’re kind of undertaking on the behavioral science side? And ultimately, when we talk about gamification is a user friendly way of presenting a whole bunch of behavioral science or behavioral economic principles. And is there a way that we use that and the high engagement that a lot of these consumer and tech products get and actually bring that day health care. And that was in many ways the impetus.

Scott
Starting Perx health was recognizing that these consumer and technology companies had really nailed the delivery of behavioral economics principles through gamification. Getting that to engage people on a daily basis and keep them engaged and around. And that has value in terms of getting people to change behavior and form positive habits. And where we need positive habits the most is arguably healthcare.

Ben
Completely agree. The challenges of 21st century healthcare are how do we get people to review their lifestyle and not just become aware of the changes in lifestyles and habits which are beneficial, but keep them and maintain them for many weeks, months, and if possible, years. So, yeah, that behavioral element, that motivation element is really important, but it’s currently a huge challenge because creating new behaviors, particularly long lasting ones, is tough. So in that case, what was your journey then to co founding? What was the principle of meeting your co founder, Hugo, creating a team, everything like that?

Scott
Yeah, I met Hugo, I think the first day of high school in the US, which is where I’m based now, it would be the first day of middle school. We’re probably 1011 years old, and we’ve been really good friends ever since. We were both working industries that I think were highly effective at deploying gamification and behavioral science to drive user behavior or consumer behavior. Hugo was at McKinsey, working in big retail industries, gaming industries, and I was at the same time kind of working in private equity, working with consumer and technology industries. And I think we both kind of identified this trend at the same time. Got talking about it over dinner one night, and then kind of thought, well, how do we actually bring this to healthcare?

Scott
And really the reason for that is both of us, like almost everyone, have family members, friends who are managing chronic illnesses or just need to kind of be managing their health more effectively. And I think what we’re kind of somewhat frustrated with is that often we use pretty plain strategies when we’re trying to motivate someone to change behavior around health care. And they’re almost always universally focused solely on education information, which is give people more information about their health, and hopefully they’ll make these changes every day for the long term and stick with them, because we’ve told them that’s important. And I think information alone is not the answer. Education is really important to health, but I think for many individuals, they see that as another task that they need to do.

Scott
They already need to take their medication, do their physical therapy, make sure they’re attending their appointments, and actually consuming information about their condition is another item on the to do list, as opposed to a reason for them to engage in their health. And so that was really, we took this kind of what were seeing in probably our professional lives, around these really high engagement products that had no issue with getting someone to come back time after time and change their behavior for the long term, but often to form habits that weren’t particularly healthy or very at best indifferent to their long term well being, while at the same time probably seeing that in our personal lives that there were people really struggling to form habits to change behaviors in ways that were healthy.

Scott
And it was that combination, that insight that really led us to start Perx health a few years ago. Now, since then, we’ve been really fortunate to surround ourselves with great advisors in the medical space, as well as team members who’ve built high engagement digital products before. I think we had a lot of theories, and particularly with all my kind of behavioral economics approach and what Hugo had probably seen in the real world in his work at McKinsey. But were also fortunate to have people who built mobile games before, who built social media or streaming platforms before joining our vision.

Scott
And I think in many ways, for a lot of the team that we’ve built at Perx, it is the opportunity for them to bring all these great skills that they’ve learned building these high engagement digital products in other industries and bring them to healthcare where they can have a really big impact. And we’re really proud of that.

Pete
I’m going to ask, so what’s it like bringing together all those different skills into gamifying an app like this or product list?

Scott
Yeah, I mean, it’s really rewarding, I think, in many ways. So inevitably, founding any startup or any new company is a bit of a roller coaster. And I’d say you’re kind of having to kind of manage lots of different people with lots of different perspectives, both in the company, but external to the company as well. When we think about the users of our product, the customers that we work with to deliver our programs. But I think one of the things that cuts through a lot of that, one of the benefits of being in healthcare is that even on the weeks when nothing goes to plan, we’ve had to kind of rerelease the product, or we’ve had to kind of have a tough discussion with the customer.

Scott
We get this feedback from the users of our product who are ultimately patients managing chronic conditions, and they talk about how they’ve just achieved six months in a row of consistently sticking to their treatment plan day in, day out, or they’ve been to the doctor and they’ve just received the best blood test results that they’ve seen in years. And I think that ultimately really helps kind of align the team around that kind of North Star of what does the company exist to achieve? And also, to be honest, it’s very rewarding. When you’ve had a tough week at work and you’ve dealt with the ups and downs of startup life, is to kind of hear that really positive feedback and positive impact that you’ve been able to have on someone’s life.

Ben
In that case, can you talk our listeners through what does it look like to engage with Perx Health’s platform and technology? What would an average interaction looks like and what are some of the game features they might see too?

Scott
Yeah, so generally we’re working with people managing multiple chronic conditions and various chronic conditions. We’ve deliberately built Perx to be condition agnostic. So it’s not a diabetes app or a mental health app or a respiratory disease app. It’s very focused on. We recognize that for most people managing chronic conditions, they’re not just managing a single condition, they’re managing multiple. And so we need to be able to help support them across their entire treatment plan. And so we’ll work with healthcare systems and health life workers compensation insurers to effectively roll out our program to those patients who need it most. Those patients who need to be completing multiple health care tasks throughout the course of the day to manage their condition long term. They’ll often be invited jointly by us and their health plan or us and their healthcare system.

Scott
And I think that’s really important. We’ve always set up Perx. We’re not here to replace what is already a best practice healthcare system, best practice health plan in many cases, and best practice treatment protocols. We’re here to really solve the problem of how do we take best practice treatment protocols and make sure that a patient is implementing them on a daily basis to achieve the outcome that protocol is supposed to deliver. And so we’ll work jointly with those clinicians, those care teams, that healthcare system, roll it out with the individuals, and then as an individual patient or an individual member of that health plan, you’ll be invited to join Perx. We’ll help you get your treatment plan set up. That might be taking daily medications or seeing your GP once every two or three months. It might be doing physical therapy once a day.

Scott
And we will then help keep you motivated, and we’ll find various different ways of keeping you motivated, and we’ll personalize it to the individual. So we might recognize that for some people, the promise of a gift card or some sort of financial incentive is really effective and change your behavior. We might find with others that actually getting them to maintain a daily streak and reminding them that they’ve got that daily streak is really effective. Others will be focused on moving up a leaderboard or participating in a challenge. Our thesis at Perx and our product approach is that ultimately there’s no silver bullet for behavior change.

Scott
That’s often disappointing for people to hear, but there isn’t just kind of one magic formula of reward, plus a little bit of gamification and a sprinkle of community reinforcement is somehow the magic formula that works for every single person. What we rather focus on at Perx is how do we deliver a really broad array of different behavior change strategies and experiences of gamification, and then over time, how do we start to personalize that for the individual? So if we recognize Scott’s really motivated by rewards, let’s give Scott more rewards. And then when we’re talking to him about the healthcare changes he needs to make, reinforce that with rewards. And if we find Ben is much more motivated by his daily streak, well, let’s not talk to Ben about rewards because he hasn’t claimed a reward in the app.

Scott
Let’s really focus him on maintaining that daily streak. And we find it fascinating, the different personalities and archetypes that we see of how to motivate people within Perx.

Ben
I would say at the latter end of the 20th century, the real shift was in personalized medicine. I think the interesting part of the 21st century is going to be personalized motivation or personalized gamification. I think what you’re doing in that case at Perx is absolutely brilliant, exactly where we need to go. And I think often Pete and I speak to a lot of people involved in different health communication programs, and a lot of it is just, there are one or two game mechanics they’ve implemented, and everyone follows the same journey. How are you personalizing it? Is it just based on usage of different mechanics or different features you have in Perx, or is there some assessment you’re doing to identify what is the right game mechanic for the right type of player?

Scott
Yeah, I mean, it’s constantly changing, I should say. Our product approach is very empirical, so we’re constantly trying something, testing and learning. And so I definitely wouldn’t say that we’re never going to do an assessment or that we’re never going to kind of try and get that information. I think we learned early on, and again, it comes back to probably kind of those behavioral science roots, is that revealed preference can be a lot more powerful than stated preference. And we learned this in an experiment where were giving out rewards and we said, hey, we want our user base to vote on the type of rewards that we deliver. And we have everything from charity donations to CVS gift cards and pharmacy gift cards that we offer through Perx.

Scott
And we said, hey, what reward would you like to receive as an incentive for sticking to your treatment plan? We had a lot of people respond. Charity donation. And then when we looked at the data, we found that charity donation was motivating for some users, but nowhere near the percentage that said a charity donation would be motivating for them. And I think we’ve got to be aware of those unconscious biases that we all have of what we like to think is actually motivating for us may be different to what ultimately motivates us. And so for us, a lot of what we do around that kind of personalization is actually focused on the behaviors that we’ve seen in the app. And this isn’t new. I mean, it’s new in healthcare. I definitely agree with you, Ben.

Scott
But if we think about what do the big consumer apps do, I mean, how does Instagram get us to scroll endlessly on our phone? How does Netflix get us to go back time and time again? Or how does a mobile game keep us mindlessly playing when we probably should be doing something more productive? They ultimately look to tailor the outreach, and that’s probably where we start on the personalization is ultimately the biggest challenge for any digital product, but particularly a digital health product, is how do you cut through the stream of 50 notifications that we’re all going to have on our phones when we finish this podcast?

Scott
And we need to think about, okay, what is the two line thing that we can say to Scott when he has to take his medication or he has to do his physical therapy that will cut through the hundred other notifications he’s got on his phone? And that is really kind of when we think about the personalized aspect of engagement, it has to be that notification resonates with something that we’ve seen has previously engaged Scott to take a positive action in his behavior. But then once someone comes into the Perx health member app, they’ll have those different aspects of gamification or behavior change salient to them. So it might be that their streak is appearing in the top left corner, or that they’re being reminded they earned a gift card last time they took their medication on time.

Scott
And those type of things can be made really salient through the app.

Pete
That’s really interesting. How do you cope with the fact that people do self select the things that have got their interest, but that interest in that type of game mechanic may fade quite quickly or not last as long. So I’m thinking, like, people get really into quizzes, but only for a week or two, and then it fades off.

Scott
Yeah, I think that’s really insightful. So we talk about how do we not just recognize that different individuals are motivated in different ways, but actually the same individual can be motivated by different things over the course of period of time. And it’s definitely a trend that we see time and time again in Perx. We might have someone who, if were to survey them on day one of signing up to the Perx program, what has motivated them to sign up? It’s I get rewards for looking after myself or managing my condition. If were to then survey them on day seven, maybe at that point they’ve realized they’ve got a five day streak now and actually they don’t want to lose the five day streak.

Scott
And then if we survey them on day 14, it might be, well, I’m moving up the streak leaderboard and I really just want to get above Pete on the leaderboard. And that’s actually my motivator for sticking around. And then if we survey them on day 180, it might be that now I’m a really active participant in the community forum and people rely on me or I have a certain level status in the community. And that really is important to me. And absolutely we see that change over time. And I think what’s important is that, and we are constantly playing around with how can we become more sophisticated in the way that we actually recognize that user journey. And if were kind of initially trying to personalize to one motivator, we start to kind of lean back towards another.

Scott
But again, we think it’s a pretty novel approach to healthcare. But when you look at the big consumer apps, when you look at the big mobile games, they’ve been on this journey as well. They recognize that not only is having a single game mechanic or a single motivator, or a single reason to engage not good enough because it limits the number of people you can ultimately impact, but it’s also not good enough because it doesn’t keep people around. And I think retention, to your point, is like one of the biggest challenges. I mean, when we talk about engagement in digital health products, people often focus on enrollment. The fact that sad reality that when a digital health program is rolled out by a health plan or a healthcare system, they usually see 5% to 10% of people actually take that solution up.

Scott
What is actually probably as shocking is that then out of those who do enroll, the typical retention in a digital health solution, and there’s a metaanalysis of 100,000 people using different digital healthcare apps, was 5.5 days. The revised analysis that came out and said it was actually closer to 4.2 days. I mean, whether it’s 4.2 or 5.5, I think it’s fair to say if you’re trying to design a digital solution for long term behavior change, for someone who’s going to have a chronic condition, unfortunately for the rest of their life, engaging them for less than a week is not going to be good enough, let alone the fact that you don’t get 95% of people up front. And that’s really when it comes to the core of it, what is the problem that Perx is solving?

Scott
It’s not that we’ve got some fantastic new way of treating diabetes. It’s not that we’ve unlocked some previously unknown way of managing a behavioral health or a mental health condition. It’s that ultimately we work really hard at knowing that what we do best is getting a large proportion of people engaged in digital health program and keeping them engaged in a way that those best practices, the best practice ways of treating that condition that often the healthcare system or the clinician already knows, we can actually get them to stick to it consistently over time.

Ben
In that case, Scott, it’d be great to know some of your stats in terms of how many people you’re engaging, how long they’re engaging for. What are you seeing in Perx compared to other digital health services?

Scott
Yeah, it’s something we’re really proud of. So we’ve run programs for large health insurers, life insurers, healthcare systems, our approach to kind of engagement and behavior change, we see 40, 50, in some cases as high as 60% of patients that we’re reaching out to enrolling in the program. And we’ve done that across populations that are really tech savvy and also populations that are much less tech savvy. You wouldn’t expect to be digital health adopters. And I think that’s really important as well. We see that then the average patient in the Perx platform is engaging 4.4 times a day. And that habitual engagement is really important to us. We see the daily active user to monthly active user ratio of Perx is 70% plus.

Scott
To put that in perspective, the top 20 behavioral health apps in the App Store average around ten to 15% daily active usage. So people are using them kind of once a week. And then I think to that stat that I mentioned earlier, where there’s that four to five days of average retention, which we really focused on because we’re going to drive that long term behavior change. The average patient on the Perx platform today has been using Perx continuously for 220 plus days. And so that’s, I think the thing that kind of we really talk to the health plans and health assistants we work with is if we really want to create meaningful change, we do need to engage the patient for over six months. And the unfortunate reality is that most digital solutions aren’t engaging people for more than six days.

Scott
And so that’s, I think, where we really hone in on how does taking a behavioral science or gamification approach that we are move the needle? Well, it’s just that step up in terms of how many patients you can get enrolled, but also how long you can keep them enrolled for as well.

Ben
Huge congrats, Scott, to you and the Perx team as well. You must be incredibly proud of that.

Scott
Absolutely.

Ben
So those are sector shifting stats that is redefining what the industry benchmarks could be. Is it just the personalization of the game features and functions that you think is a major driving that? Is it that you’re recognizing that it’s not? One generic gamified features is working with your users, your players to go, this is what you should focus on, your motivation. And is it that alone that you think is resulting in that much increased engagement and retention?

Scott
Yeah, I think there’s probably a bunch of things that sit below the surface. I mean, the first level is just having a really broad range of motivators. So stepping back from personalizing, it’s the recognition that there is no silver bullet. And then to your point earlier, it’s not just putting one or two game mechanics in there and saying, okay, well, now it’s no longer an education app. It’s an education app plus gamification.

Scott
And recognizing that actually, as Pete mentioned, if you just have a single engagement strategy or a single game mechanic, not only are you going to miss out on a huge population, a proportion of the population who aren’t motivated by that game mechanic, but you’re also arguably, even those who are interested in that game mechanic initially are probably going to drop off after a week or two when that becomes not so novel and not so interesting for them anymore. And so I think having a really broad suite of motivators is powerful and enables you to kind of engage more people.

Scott
It enables you to engage the person who’s not interested in shriek, in a shriek because you have a leaderboard or because you have a reward or you have a leveling up mechanic, but it also then allows you to kind of keep those people shift their interest as it might weigh in one of those features to another feature. I think that’s been really important and I think also the approach we’ve taken to actually building out what we would call habit loops. And so when we talk about how do we get someone to complete an individual task, let’s say it’s medication, how do we get someone to take the medication this morning? Well it’s really important to have positive reinforcement of that task. But then it’s equally important that we make sure that person comes back and takes their medication in the afternoon.

Scott
And so then what we talk about is how do we form a habit loop around that day? And maybe you’re using a different feature or a different mechanic to get them to complete every task in the day, then it’s okay. How do you get them to complete a perfect day of adherence every day in a week? And maybe there’s a different mechanic around that week. And a lot of that comes from some of the research out there into behavior change and engagement with digital products. Near Il kind of had a great book on hooked which was talking about specifically that you need to kind of build these reinforcement loops over different time periods and investment is kind of the final stage of his hook model.

Scott
It’s how do you get someone to come back day after day, week after week, year after year after year. And we had an amazing kind of instance in our community which is kind of a forum where patients can connect with other patients in app where someone came in the other day and celebrated that they just achieved an 1000 day streak which was 1000 days in a row of doing every single healthcare task that they had to. And I think that shows some of the power of thinking about the habit loop both in the moment but also stacking up days, weeks, months, years.

Ben
Points and badges wear off over time. And I agree there’s only so many points and badges that will keep you going. But the idea that even within the same day to create that habit, Luther, you defined it to look at what is the different mechanic that’s going to make them engage again to do another health behavior or repeat their health behaviour that’s needed. I think that’s really pioneering, Scott. In terms mean. Yeah, Pete and I get to speak to a lot of different health gamification services products, but the ongoing dynamic adjustment and change of that mechanic being used and implemented to create that behavior in the same day alone. Yeah, absolutely brilliant work.

Pete
I’m wondering what the critical mass is by the way. How many different game elements or game mechanics do you need?

Scott
Yeah, I mean it’s a good question. I think for us, we often say that the Perx product is never going to be complete. I think what we really love doing is kind of just coming up with different mechanics, running experiments and seeing does this work? Does this work for a subset of the population? Does this work in terms of driving retention or improving enrollment or improving that frequency of engagement? We’ve run lots of experiments. We’ve had some that work, we’ve had some that didn’t. I think we had an incredible experiment that we ran really early on. I think we interviewed someone who had done a lot of research in the behavior change space and actually had developed a solution back in the 80s or ninety s for weight loss using kind of incentives.

Scott
And we said to him, okay, if you were building this today, what would you do? And he kind of said, I’d lean heavily on social. And so we actually ran an experiment really early on where we kind of just connected a few of our members who we knew were power users and said, what if we put you in two groups in the community? You’re in teams, you can name your teams, and then it’s a group challenge. And so I think from that perspective, were then able to kind of see, okay, if you kind of do a collaborative competition, what’s the results look like? We had one group that achieved 100% adherence across all their healthcare tasks as a collective team over the course of a couple of weeks. The second group achieved 99% adherence that missed effectively one task.

Scott
And I think running those different experiments and implementing them and then playing around with their implementation and then also combining different aspects as well. I saw a great post recently from one of the Duolingo product managers around combining kind of streaks with the commitment device. And I think you’ll be seeing a lot more kind of those combined different kind of game mechanics coming together. Yeah, we’re constantly iterating, playing around. I don’t know if there is a critical mass. Maybe there is, but I think we will be constantly learning and testing different mechanics, different approaches to behavior change.

Scott
And I think that’s part of what does make the way that our kind of product team and engineering team work really unique is that it’s a very empirical, experimental approach, as opposed to saying just okay, we read this paper, it had this concept of behavior change. Therefore, we’re going to embed this and we’re not going to follow up and see if it works or test to learn. And then we also think about how does that interact with the other game mechanics or the other behavior change devices that we have in app already.

Pete
I think that’s really good. You’ve not answered the critical mass question, but I get it. The bit that I’m interested in, that I’ve seen other apps and things really struggle with, is when you’ve got a bigger range of game elements and mechanics, how do you still make it feel like one cohesive experience? How are they interlinked? Do you have a theme that glues them all together? What are you doing with that?

Scott
Yeah, I mean, I think it’s a really good question. I’d say that ultimately, the way that our product works is it’s obviously very centered around completing health behaviors. And if you come into Perx, the first thing you see is not necessarily the game mechanic. Maybe that’s the notification that draws you in, but it is ultimately that health to do list. What are the things that you need to do? And then almost all of the behavior change and game mechanic strategies are in service of getting that to do list completed. And I think that is, if I was to kind of align, what is theme? It’s around, how do we positively reinforce the completion of those health behaviors through those various mechanics?

Scott
I think that, yes, you need to be careful about overly kind of confusing or bombarding the user with ten different reasons why you should complete that healthcare task. But I think we’ve done a great job at really centering it around as much as we’ve got all the novelty of the points, the leaderboard, the streaks, the gift cards, it is all centered in on. This is about getting your daily to do list complete and coming back tomorrow and doing it again.

Scott
And I think that probably means that, as opposed to where it might just be a game for game’s sake, where you’re kind of like, am I focusing on moving up the leaderboard or am I focusing on getting a 20 day streak, or am I focusing on leveling up for us, it does all come back to yes, the main thing here is actually making sure that you are progressing on your health journey and everything else is a nudge or a positive reinforcer in the right direction.

Pete
So would you say the language that you have to use with your communications with each player is very much about reinforcing the meaningful purpose of what they’re doing?

Scott
Yes, I would say that what is really important is setting kind of clear expectations and goals with people up front around. Ultimately, what we’re trying to do here is help you progress on the journey to managing your condition as best you can. Yes, you can win a gift card. Yes, you can kind of level up. I mean, I think ultimately the most positive reinforcer for them is that they see that their blood pressure has come down or their blood glucose is under better control, or that they’re feeling healthy and they can spend time with their kids or their grandkids. That ultimately is the biggest reward in all of this is the people being able to see that step on the journey, that kind of change in their health. That is the ultimate positive reinforcer.

Scott
What I’d say is that, unfortunately, it takes a lot of little steps to get that to that point. You can’t unfortunately change someone’s blood pressure to being controlled overnight. You can’t help someone lose a huge amount of weight over in a really short period of time. You can’t get someone to take their metformin to manage their type two diabetes. Their blood glucose is under control or their HBA one c results under control. Those things take time. And I think what we have struggled with, and there’s some great research on this, is that you don’t want to.

Scott
Focusing someone on the goal, I mean, is important, but you really need to focus them on the steps to that goal and actually positively reinforce, not that they hit the number on the scales or the number on the blood glucose monitor at the end of six months, because it’s really hard to stay motivated when you can’t see any change over that six months. What you really need to positively reinforce are the little steps along the way. And I think that’s what Perx does really well, is like, in many ways, the gamification and the behavior change strategy that we use in Perx are in service of getting someone from month zero to month six and do all the steps that they need to along the way.

Scott
And then the ultimate positive reinforcer is that they come back from the doctor and they have better controlled blood glucose or better controlled blood pressure. And so I think in many ways, what we’re doing is in service of getting them there and keeping them engaged and adherent to those step by step goals, as opposed to the little change every day that they need to make, as opposed to just solely focusing on that big, hairy goal at the end of the journey.

Pete
I think that’s a really interesting approach because, in essence, you’re rewarding effort that people put in, which is that’s how you make people more resilient as well, isn’t it rewarding effort?

Scott
Absolutely. And it’s ultimately the thing that they can change. And I think that’s really hard. I think we’re all about how do you make every step that someone needs to take towards the goal rewarding, as opposed to rewarding the goal. And I think that’s often a mistake that we make, not just in healthcare, but in many areas of society.

Scott
We focus people in on lose the ten pounds or kind of save this amount or those type of things, as opposed to the steps that people can actually control a lot more effectively and are the little things that add up to the big thing at the end of the day, and I’m trying to remember, there was a specific book that had a really good section on this, which I think was atomic habits by James clear, which specifically broke down that ultimately what you need to focus on is the systems and the day to day steps, as opposed to that kind of big, audacious, hairy goal. That seems really scary because it is.

Pete
Now, you mentioned the really sort of positive feedback people get, like, I’m having a better lifestyle, playing with my kids, more stuff like that. How are you able to capture that sort of information and show it in the game, in the app to remind people? Are you relying on them self putting it in?

Scott
Yeah, we have different programs that we run where we can actually surface that data up through like an integration we might have with a healthcare system or a health plan partner. We are also integrated with all Bluetooth devices. And I think one of the really interesting things is we talk about adherence, and people naturally jump to medication adherence because I think that’s where everyone’s familiar with the challenge, or most people are familiar with the challenge of 50% of people don’t adhere to their medication the way that they should. The reality is we have adherence problems all over the healthcare system. I mean, people aren’t doing the. My mum’s a physiotherapist and the first thing she would say is that people don’t do their exercises that I’ve prescribed them, except for when they’re in the chair sitting across from me in pain.

Scott
They don’t actually do the preventative stretching or the preventative exercise they need to. Similarly, we see people not attending appointments with specialists and clinicians as regularly as they should to have those checkups. And then the other one, I’d say, is actually getting people to use devices. In the US, where I’m based, there’s codes that effectively, people can run a remote patient monitoring or remote therapeutic monitoring program where you effectively give a patient device and you track that and you can record those measures. And we see with the array of fantastic devices that can measure anything and everything. That’s very popular. I’d say we have an adherence problem with getting people to log those measurements as well. Often the blood pressure monitor or the scales are collecting dust on the shelf or under the sink and not actually being used.

Scott
And so what we can actually do with Perx is not only make sure that we’re surfacing those great outcomes, so they are improving their blood pressure, but also we can use the same motivation and gamification and behavior change elements that we have in app to encourage them to take that measurement more regularly so they can see that progress. And I think that’s super important for the patient as it is the healthcare system or health plan partner who might be delivering a remote patient monitoring program, but getting frustrated that they’ve sent all these devices out and no one’s actually logging a measurement.

Ben
What we’re going to go into now on the Perx website, you mentioned the research you completed. What research have you completed? What was your motivation to go and complete that research and what has it shown in terms of the effectiveness of Perx.

Scott
Yeah, we’re really proud of the research that we’ve done. I think we’ve always taken the approach and it probably comes from that kind of experiment, iterate test, learn approach we have in product to how we actually validate the clinical impact and the behavior change impact that we have. So our first ever customer was effectively one of the largest public healthcare systems in Australia, and that partner was really clear on the people were working with were all clinical and they wanted to see, have you actually validated that this works? They very kindly introduced us to the University of Sydney and suggested that they run a clinical study of looking at Perx, its impact on patients managing complex chronic conditions.

Scott
And actually the patients that were enrolled out of public healthcare clinics, they were managing multiple chronic conditions, they were older, in many cases, they’re managing multiple chronic conditions and quite a complex treatment plan. And so we really kind of, in many ways, it was a bit of a trial by fire. Probably some of the hardest patients to change behavior with were the patients that we had recruited and enrolled in our clinical trial. And we ran that for twelve months. We looked at their behavior over twelve months, but we also measured biomarker outcomes. And so those patients were generally managing complex diabetes and cardiovascular conditions.

Scott
The results of that study were actually published in the British Medical Journal and then also picked up at the American Journal for Managed Care and found that the patients using Perx versus standard care were achieved twice the ods of adherence to their treatment plan. And that was validated through kind of effectively, medication, pill counts and dispense rates, but also that we saw a specifically significant impact on underlying biomarkers. So greater diabetes control, greater cholesterol control, which shouldn’t be shocking, I mean, we’re really proud of it. But if you can get patients to engage with their treatment and do what their doctor has asked them to do and take the medication their doctor has prescribed to them consistently for over twelve months, you start to see those health impacts.

Scott
And something we’re really proud of and is really important to us as an organization knowing that, yes, it’s great that patients engage with our member app four times a day. It’s great that they do that for over 200 days, but actually, does that lead to better outcomes when it comes to them doing what they need to do and ultimately having a better quality of life and better results when it comes to managing their chronic condition? So that’s really important. We’ve also been fortunate to now actually work with a number of universities on other kind of analyses looking at Perx’s impact in different condition areas, whether it’s mental and behavioral health, whether it’s respiratory conditions or musculoskeletal conditions, and also with the partners that we work with.

Scott
So we work with a lot of insurers who then look to kind of validate, okay, yes, you’re having a great impact on engaging those patients. Yes, you’re having a great impact on improving their adherence, but also what’s the impact on claims costs? Are people ending up in hospital less frequently? Are people actually staying out of hospital? And therefore it’s not incurring as big a costs on the bottom line. And the pleasing thing there has been that we’ve seen time and time again that behavior change translates to health outcomes, translates to economic outcomes. In many ways it becomes a win for both the patient having better health, but also the partners that we work with.

Ben
In that case, you mentioned insurers there. What’s the business model you’ve taken on as Perx and has that evolved and changed much since day one?

Scott
Yeah, I mean, we’ve probably kept pretty straight to the business model in that we work with large health plans, large life insurers and workers compensation insurers and healthcare systems to roll out programs for their patients. And they can be targeted to a specific condition area. In many cases, it’s actually across multiple conditions because that tends to be their highest risk and highest cost patients managing multiple kind of conditions. We effectively deliver that program by half of the plan, and the plan pays for that program for their patients because ultimately they’re the ones who see the economic benefit of their bottom line when that patient isn’t unnecessarily ending up in hospital because they’re struggling to stick to their treatment. And so that’s the business model that we found works most effectively.

Scott
It best aligns the economic incentive and also makes sure that we can deliver Perx to anyone, as opposed to necessarily just those who can afford it. And I think that works well.

Ben
What’s the volume of users? You’ve had Perx to date, and also you mentioned Australia as well. You’re based in the US, kind of. Where are you operating and working?

Scott
Yeah, sometimes I get a little bit confused that between time zones and going back and forth, I mean, I’m based in New York. I have been for over a year now and been back and forth for the last two or three years. We’ve had over 30,000 patients use Perx through various programs that we run now. That’s actually as many people in the USing Perx as Australia. As people could probably tell from the accent. I’m originally from Australia, but we very much started and we work with a lot of the large insurers and healthcare systems in the australian market. Actually about three years ago now, just before COVID we launched with our first customer as a Texas based healthcare system. That program has grown phenomenally well and been very successful.

Scott
And then I then started when things started to kind of COVID started to ease up and restrictions started to kind of go away. I started traveling over to the US more. We now have a great team in the US and I’m based here full time because obviously there’s a huge opportunity with the large number of insurers, large number of healthcare systems in the US market. And that’s our principal focus is how do we keep growing into the US market. And we have a number of health plans that we’ve launched with that we’re really excited about and others that we’re working with and preparing to launch programs with them.

Ben
Outside of Perx, are there any examples of health gamifications that you’ve liked the look of that you find interesting, that you thought that’s something novel and something that you’d like to pursue in the future too?

Scott
Yeah, I think we’ve always been really focused on the high risk, high acuity end of the healthcare spectrum. So most of the patients that we’re working with are managing multiple chronic conditions and have very clinical treatment plans that they need to stick with. And we really like that. I mean, it’s where we can have the biggest impact with what we do. We’ve built a really high engagement product. People are using it four or five times a day. I mean, ultimately, that’s because they need to be engaging with their health care four to five times a day because they’ve got so many complex tasks that need to be completing.

Scott
I think I’m equally really interested in people who are applying similar principles in the wellness and fitness space and making sure that we’re kind of actually operating the other end of the spectrum where we’re helping people prevent the development of chronic disease. I don’t think Perx is not really focused on that end, and I don’t think it will be. I mean, we’ve got a huge problem to solve on the chronic disease space, but I am really interested in kind of learning kind of what’s working. And I think off wrongly assume that the challenge of exercising, eating healthily, getting to the gym, going for that run, somehow that’s a different behavioral problem to getting someone to take their medication, log a blood pressure measurement, do their physical therapy.

Scott
Ultimately, we’re all humans and those small tasks that we need to do every day to kind of get to those big goals, whether that goal is reducing your blood glucose or maintaining a healthy weight. And I see it time and time again where you come up with someone who maybe hasn’t experienced a chronic disease firsthand and isn’t managing a chronic condition, doesn’t quite appreciate how complex an ass that is, and will say, oh, I don’t understand why people don’t take their medication. Don’t they know that it’s life saving or it’s important to managing the condition? And if you turn that round back to that person and said, okay, well, how often do you eat a healthy meal? Or how often do you get to the gym?

Scott
We all know these things are important to our long term health, but we all struggle, wherever we are in the health spectrum, to do those tasks that we know we should be doing on a day to day basis. And so I think there’s some really interesting stuff. And I love using Strava. I kind of like running and writing, and I find it interesting, some of the mechanics they play around with, some of the challenges and the accountability it creates when you’re seeing all your friends got out and did something, got some exercise in this morning, and I think that’s really interesting. And how do we kind of build more positive incentives and positive kind of gamification features into maintaining a healthy lifestyle and wellness? And so there’s probably a number of kind of different ways that we can approach that.

Scott
And I think there’s learnings that we can probably take on both ends of how do you drive the multiple times a day very clinical adherence product that we have, but also then that kind of wellness and well being kind of end of the spectrum as well.

Pete
I think that’s really interesting, particularly when you were talking about like your user who had 100 day streak of taking their medications and doing whatever it is they need to do each day. And I’m thinking in a lot of products and apps, people’s lives don’t fit with an everyday thing. They always have a day off. And yet with a medical routine that you have to do, you have to.

Ben
Do it every day.

Pete
And I think that’s really impressive. What you’ve done there is reminding them of that. I’ve got a question, a more philosophical question really, which is generally, I think about gamification as a scaffolding that helps people build new habits, and then eventually you shouldn’t need the gamification anymore. So where do you think that stands with your personalized long term engagement approach? Do you think people managing chronic conditions actually will always need the help because they’ve got a lot to do each day? Or will it just become a habit? And can you say yes successfully, you.

Scott
Don’T need us anymore, we’ve changed behavior, they don’t need us anymore. I think it’s a really good question and it’s something that we talk about a lot, particularly with the health plan clients that we work with or the healthcare system clients that we work with about should this be a six month program that we offer people? Should this be a twelve month program that we offer people? Or should we just make it perpetually available? I think the reality is that, yes, ideally you have a kind of magic wand where you can make someone hyper rational by using Perx for a period of time and they never have to really think about it again. It just becomes habit.

Scott
I think the unfortunate reality in the chronic condition management space that we work in is for a lot of people, their treatment plan will change a lot over time. And so maybe they were taking a blood pressure medication once a day and having to take a blood pressure measurement every couple of weeks. I mean, the reality of that evolution over a couple of years is that they may now have a more complex treatment plan. They need to be managing new medications, they may have developed a comorbidity, and there’s additional treatment plan tasks. They might need to do physical therapy now for the knee and there’s going to be those habits that we need to do are changing in the chronic condition space over time. And so I think you wouldn’t want to kind of pull it.

Scott
You could imagine someone who may be just using it to manage a cardiovascular condition, and you give it to them for six months. They seem to be taking that one blood pressure medication really well. Some catastrophic event happens and then now they have a whole new treatment plan. They now need to do physical therapy, they need to do cardiac rehab or something like that, and now they’ve got ten tasks they need to do over the course of the day. And it’s different frequencies, it’s more tasks, more appointments that they need to manage. And so you wouldn’t want to at that point be like, okay, well, you’ve had Perx for six months without taking it away when the whole kind of world’s turned upside down. And that’s where people really have to effectively reform habits.

Scott
So we play around, we’re talking to kind of health plans. We also talk to our patients about how are you finding your experience with Perx. Do you feel that it’s still helpful? Do you feel like you’ve still had gotten a habit? I mean, we’ve definitely had people where we’ve kind of sent them a reengagement survey and said, hey, you’re a power user for twelve months, and then you stopped using it. What was that? Obviously we want to understand what that is. And in that case, we’ve heard many times, yeah, I’m in the habit now, and I just didn’t feel that I needed it as much. And that’s obviously a bittersweet thing to hear because we’re very focused around this long term engagement.

Scott
But you’re like, well, if you feel confident and you kind of are managing your know that, then maybe there isn’t the role there for know, at this point in time. But yeah, I think it’s an interesting thing. I mean, I don’t think Perx believes in just engagement for engagement’s sake. I mean, it’s engagement in service of getting someone to stick to their treatment plan, see better health outcomes. If they do need us again, we’ll be there. But I think that’s a really interesting question, Pete. And I think the unfortunate reality is with the typical engagement of five days in digital health products, it’s not a question that unfortunately has had to be asked too much in digital health yet, but, yeah, definitely something we think about.

Ben
Great answer.

Pete
Thank you, Scott.

Ben
It’s been fantastic to have in the show on today to talk through taking an empirical approach with game feature identification design implementation and then validating those with academic research creating business models for health gamification services that align to the economic incentives for health systems and health insurers, which impact their bottom line, creating new revenues for Perx and that there’s no silver bullet game mechanic. It’s the tailoring of gamification features to create personalized motivation for every user, which can lead, in Perx’case, to industry defining engagement and retention stats. Scott, it’s been brilliant to have you on, and we’re looking forward to seeing the growth of Perx in years to come.

Scott
Really appreciate it. Thanks for having me.

Pete
Thanks for being on. Scott. It’s been really interesting. 

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