Paid to get healthy

In theory, everyone can be bought if the price is right. So would you stop smoking, lose weight or do something to lower your cholesterol if you knew there were an incentive involved?

Under the federal health care reform law, a $100 million grant opportunity is being offered to states, allowing them to experiment with a rewards system for Medicaid recipients who make health-related lifestyle changes. States have until May 2 to submit an application if they’re interested.

Kaiser Health News explains how the project is supposed to work:

Medicaid enrollees who demonstrate a commitment to improving their health will be eligible to receive financial rewards, such as coupons or gift certificates. For those who are overweight or trying to quit smoking, that commitment might take the form of weight management classes or tobacco cessation counseling. States are encouraged to provide rewards “on a tiered basis” for attempts at participation, “actual behavior change,” and “achievement of health goals.”

The idea is to try to reduce chronic disease among this low-income population, a move that presumably will help save money.

Sounds like a good idea, yes? But the big question is whether this approach actually works.

The concept isn’t exactly new. A handful of states are already using some form of incentive for Medicaid enrollees. Idaho, for instance, offers $200 worth of vouchers that someone on Medicaid can use to visit a doctor to discuss weight loss or smoking cessation. And in the private-sector business world, a number of corporations have tried a rewards system to encourage healthy behavior among their employees.

Unfortunately, there’s only limited evidence so far that this approach results in any sustained or long-term payoff. According to the Kaiser Health News article, participants in Idaho’s Preventive Health Assistance initiative seem to like the incentives but there’s been little indication they’ve led to changes in health-related behavior or lower Medicaid costs. In Florida, where a five-county program allows Medicaid enrollees to earn up to $125 in credits annually for getting flu shots and the like, most of these credits have been spent on immunizations and routine doctor visits that people would probably have sought anyway.

A rather interesting study that examined the impact of financial incentives on smoking cessation rates found that study participants who received money were much more likely to quit. The study, which appeared in February 2009 in the New England Journal of Medicine, tracked 878 employees of a multinational company who were randomized to simply receive information about smoking cessation or information plus money – $100 to complete a smoking cessation program, $250 if they weren’t smoking six months after enrolling in the study, and $400 if they remained abstinent six months after completing the cessation program.

Although this sounds promising, a couple of points are worth keeping in mind. First, this study was carried out in the corporate world and might not necessarily translate to the low-income Medicaid population. Second, smokers weren’t tracked long term, so there’s no way of knowing how many might have fallen off the wagon after the study ended.

Indeed, long-term sustainability appears to be one of the most challenging issues with health-related incentives. At the moment, there isn’t enough research to address this one way or the other. From the Kaiser Health News article:

Few behavioral studies have attempted to determine whether people who receive the incentives are able to maintain their short-term success long term – the ultimate goal of incentive-based prevention programs. Fewer attempts have been made to address how the design of an incentive program should be adjusted according to the demographics of the target population, such as [e]nsuring that low-income participants have transportation to get to appointments and classes.

The larger problem I see with incentives is that they tend to operate in isolation from other health-related factors such as the work and home environment, family dynamics and psychosocial stressors. Employers can offer their employees a $100 bonus to quit smoking, but if company policy continues to allow people to smoke outside the back door or on the loading dock, the environment isn’t exactly conducive to quitting. Low-income households can be given vouchers for fresh fruit and vegetables, but if there isn’t a neighborhood store with fresh produce or people don’t know how to properly store and prepare fresh produce, the vouchers are mostly a short-term, limited fix. Sustained behavior change generally needs to happen at a deep level, deeper than what a $100 bill or a handful of coupons can accomplish.

It’s entirely possible that some states will design an incentive program that leads to meaningful improvement in the health of the Medicaid population. But if I had $100 million in federal grant money to dole out, I’d rather see it spent on projects that improve social and community environments in ways that are sustainable and long-lasting.

Photo: Wikimedia Commons

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