What Works in Financial Incentives

Health care involves human behavior and there is a lot of general research on factors affecting human behavior and an increasing amount of research specific to health care issues.  A recent research review published in the International Journal of Behavioral Medicine examines what works in providing financial incentives for health behavior change and wellness.  The authors also explore what they describe as the ethical or moral dimensions of offering incentives for behavior change.  (IJBM Article)  In general, the research finds that financial incentives can be successful in modifying behavior, but usually work best in the case of simple, time-limited behaviors, like getting shots or going to health education classes, and are less effective for more complex behaviors like smoking or weight loss.

Mixing incentives with other intervention components, like coaching or education, is more successful, but it is obviously harder to know what part of the overall intervention deserves the credit for the success.  It is unclear whether the effects of offering incentives diminishes or disappears once the incentive is no longer available.  The authors suggest that financial incentives work best and are most appropriate when there are clear, reliable and accurate measures of the behavior and objectives desired; when the incentive has a relatively large size, when it is offered closely in time to the desired behavior, and probably in repeated fashion and when it is a positive rather than a negative incentive.

In regard to the “moral aspects” the authors suggest concerns regarding patient autonomy and interference with the doctor-patient relationship.  The second seems rather easily dispatched–if a provider is unable to encourage desirable behavior change then the use of incentives to aid in that goal seems more than justifiable.  The first is more complex, but bribing people to do what seems to be in their own best interest, and what usually is consistent with at least their own verbalized goals, doesn’t seem particularly evil.  Of course, the best incentive of all is simply to ensure that people endure the full consequences of their own behavior, good or bad.  People who take care of themselves, for example, should pay less for health care; and those who refuse to do so should pay the full cost of the health care they subsequently need.  That would be real “social justice.”