Over the past decade policy research has started to examine whether or not we should be rewarding patients with financial incentives for healthy behaviours. The studies that examine that question – which include challenges ranging from smoking cessation to completion of screening tests – and the commentary on those studies’ results provide valuable insight for anyone seeking to create better and more efficient healthcare.
We’re still in the early stages of accumulating research; most studies only report outcomes within 12 months of the reward intervention. Still, dosage a systematic review published in March 2014 concluded that the evidence thus far shows that rewarding patients is more effective than usual care for encouraging healthy behaviour change.
Since that review, check two noteworthy additional studies have been published.
The first looked at how to increase the number of patients who complete FOBT testing after receiving instructions and a collection kit. It found that offering patients a 1 in 10 chance of winning $50 led to 20% more patients completing the test. However, price compensating every patients with $5 – a financially equal outcome to a 10% chance of receiving $50 – did not significantly change behaviour.
That illogical result is consistent with evidence from the field of cognitive psychology, which has repeatedly demonstrated that emotion often trumps reason when evaluating comparative choices. That means that health researchers should be looking to that discipline for guidance when planning future experiments.
The second study, which compared four ways of rewarding patients to quit smoking, received wide coverage because it demonstrated that an $800 incentive led to 16% of patients quitting as opposed to just 6% of those who received guidance, behavioural therapy and nicotine replacement. It also showed that giving simple rewards had greater success than when patients were required to initially deposit $150 of their own money, a deposit that they lost if they failed to quit.
Regrettably, almost all the reporting overlooked what might be a more important finding: among the minority of subjects who were willing to be randomly assigned to either the simple incentive groups or the ones where they put $150 of their own money at risk, the success rate was 20% higher in those who were prepared to have some “skin in the game”. That points to strategies for assessing a person’s prospects for giving up an unhealthy behaviour.
Though we await longer-term research trials to see whether initial success persists, it’s clear that we already have reasonable evidence supporting the tactic of rewarding patients for changing behaviour. And being evidence-based is a foundational ethical requirement for patient interventions.
Nevertheless, ethics is one of three domains of commentary that question the wisdom of financial incentives. The other two are political philosophy and simple politics.
Ethicists express concern about several issues. Will a targeted patient have the right to decline without being penalized? Is the intervention truly in the patient’s best interest? Will all the risks and benefits be disclosed? And will the rewards by offered without inappropriate discrimination? Though it’s obviously possible to design financial incentives that address these concerns, policymakers will have to be mindful of them (see this previous post on ethical healthcare policy made easier).
From the perspective of political philosophers, offering rewards is a questionable state intervention in an individual’s life choices. Commentators’ responses are aligned with their views on how we should organize healthcare insurance, with advocates for universal coverage arguing that if financial incentive payments to patients lower overall costs then we should judiciously use them.
However, even societies that accept universal health insurance have trouble with the idea of rewarding some patients for actions that others do without compensation. That’s because humans are most willing to collectivize their finances to protect against risk – whether through insurance or taxation – when the risk seems a matter of luck: disease, accident, natural disaster, unemployment etc. But when negative behaviours are the result of individual choice – smoking, excess alcohol consumption, overeating, being sedentary – the politics change significantly: people begin to ask why they are paying for others’ sins.
It’s a good question. But in many cases it’s possible to reward patients to stop unhealthy behaviours without relying on people who take better care of themselves. That’s because smoking, drinking and eating involve consumption and what we can consume we can tax. If we apply a small surtax to tobacco, alcohol and obesogenic foods (see this previous post on avoiding fat, sugar and salt for where we should start) we can use that tax to fund the rewards, creating a system whereby bad behaviour funds rewards to stop bad behaviour.
Better still, as the number of people who dangerously consume falls, a shrinking group will have to fund the rewards, which will mean that the tax will have to steadily rise. That will create an ever-growing penalty to those who persist, raising the total benefit of quitting or cutting back.
A thornier issue is exercise, where the behavioural challenge is underconsumption rather than overconsumption. Though we have lots of new and affordable technology to measure a person’s physical activity, it’s hard to believe that state monitoring of our exercise will be politically acceptable. However, private insurers might propose contracts that require such disclosure. We’ll see.
There is a final point to make about rewarding patients for better health behaviour. Lost in the ethical and political arguments is why we have needed to research new ways to modify behaviour: patient education, our longstanding intervention of choice, turns out to be largely ineffective. Study after study has shown that resource-intensive individual counselling achieves little or no reduction in harmful outcomes (see this earlier post on our excessive faith in the power of enlightenment).
That means that if rewarding patients to change behaviour turns out to either lack long-term benefit or be politically untenable then we are going to have to look to new ways to get people to change their ways. Because, like or not, what we’re currently doing isn’t working.