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The New Health Care

Paying People to Be Healthy Usually Works, if the Public Can Stomach It

Credit...Pete Ryan

Few people seem comfortable with the idea of paying patients to do what we want them to do.

That’s unfortunate, because there’s a significant amount of research that says this works.

I’m not talking about things like wellness programs, which offer reductions in insurance premiums if you do what your employer wants. Those are really a means of cost-sharing in which expenses are shifted onto people who are less healthy. I’m talking about paying incentives directly to people in exchange for changes to their behavior or health.

A recent study published in the New England Journal of Medicine compared various programs that encourage people to quit smoking. The interventions were altered with subtle changes to see what types of programs might achieve better results. In the most successful one, people earned large monetary rewards — with a catch.

Smokers were enrolled in a smoking-cessation program in groups of six. They were checked at 14 days, 30 days, six months and one year. At each of the first three checks, participants received $100 for each group member who was still abstaining from smoking. They could earn up to $600 at each of three time points, as well as a $200 bonus available at six months. In other words, they could potentially earn up to $2,000 each for quitting, depending on how many in their group remained smoke-free.

These incentives worked. At six months, 16 percent of the participants in this program remained smoke-free compared with 6 percent of those who quit through other methods, without such payments. Although about half of these people reverted to smoking by 12 months, so did half of those in the control group, meaning that the program still resulted in significantly more people quitting smoking.

Knowledgeable readers might be surprised, as a meta-analysis of similar interventions published in 2011 showed that most such rewards programs focused on smoking cessation didn’t show significant results. But a careful read tells a different story. The different incentives in these studies included smaller amounts of cash or other prize draws, vouchers for goods and services, lottery tickets and meals. Only one trial included significant, direct cash payments (of up to $750), and that trial showed a positive result.

This isn’t the first study to look at financial incentives to change patients’ use of harmful substances. Monetary incentives significantly improved outcomes for addiction, weight loss and treatment of people with chronic diseases.

A 2007 report found that financial incentives were effective when they were applied to encourage people in clearly defined short-term, simple tasks, and also in encouraging them to take part in lifestyle programs. A comprehensive report prepared by the University of Minnesota Evidence-based Practice Center for the Agency for Healthcare Research and Quality in 2004 found that it was possible that increased incentives could achieve bigger responses.

This isn’t to say that paying patients is the magic bullet we’ve been waiting for. Many of the studies I’ve cited show that behaviors change while incentives are offered, but that once they are removed, people go back to old habits. Others show that while we can get patients to comply with some simple demands through such incentives, complex behavior change is harder, and not as easily influenced.

Often, though, the most difficult aspect of many of these programs is that they prove unpalatable to the public. Sometimes that’s because the behavior that we’re trying to achieve is unpopular, as with a controversial program that paid drug users to use long-term birth control or to be sterilized. Other times, it’s because it seems odd to pay people to do what they should already be doing in order to remain healthy. If they’re not incentivized themselves to go to appointments, take their medications or alter their behavior, then why should we pay them to be?

This is especially true when it comes to behaviors that we all know are unhealthy to begin with. Paying people to quit using harmful drugs or smoking can seem too close to rewarding people for adopting such habits in the first place. These incentives are not available, after all, to people who weren’t smoking or doing drugs already.

But if we take a societal perspective, then it may be in our best interests to get past many of these mental roadblocks. An economic analysis of the recent New England Journal of Medicine study showed that the rewards program I mentioned cost less than $1,200 for each person who was smoke-free at six months. We have no problem spending a lot more than that for many, many other things that are far less beneficial than quitting smoking.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine. He blogs on health research and policy at The Incidental Economist, and you can follow him on Twitter at @aaronecarroll.

The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our newsletter.

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