Analysis of the NEJM Catalyst Insights Council Survey on Engaging Patients — Health Incentives That Work (and Those That Don’t). Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
By Charlene Wong and Namita Seth Mohta
Initiatives to improve patient engagement come in a variety of forms. While insurers, employers, and health care providers are all involved in using financial incentives and penalties for engagement efforts, improvement in health outcomes has been elusive. Achieving that ultimate goal will usually require a combination of financial and social approaches.
Responses to a survey of NEJM Catalyst Insights Council members in January 2019 suggest that financial incentives alone are not enough to move the needle to realize patients’ health goals. The most effective approach to engaging patients to realize health goals is family/friends support (chosen by 35% of respondents), followed by education (30%), clinician support (30%), and financial rewards for healthy behaviors (27%).
Charlene Wong, MD, MSHP, is a practicing adolescent medicine pediatrician, health services researcher, and Assistant Professor at the Duke University Department of Pediatrics, Duke Clinical Research Institute, and Duke-Margolis Center for Health Policy. She says that financial incentives have a reputation for providing uneven results when it comes to modifying patient behavior.
“I hear a lot of skepticism around the use of financial incentives,” says Wong. “There are a lot of concerns that, number one, we’re using an extrinsic motivator that’s going to crowd out the intrinsic motivation that people need to find that would be potentially more sustainable.”
“And number two, the presence of real sustainability is limited. Patients change their behavior while the financial reward is on, but when you take the financial reward away, in almost all of the studies that I’ve seen, that behavioral effect diminishes quite quickly. So, the evidence behind the financial rewards for health behaviors is certainly mixed.”
Several factors contribute to the inconsistent effect of financial incentives in modifying patient behavior. Along with the lack of sustainability, the impact of monetary rewards can become minimized if delivered in the form of a biweekly paycheck or if the reward takes the form of a premium reduction that comes once a year at insurance plan renewal time.
In contrast, approaches rooted in social aspects such as the support of friends and family may have more lasting impact because the people involved will, at least theoretically, have permanence in the patient’s life, says Wong.
“When you put people in teams so they can have that social support, it can be beneficial for changing behavior, particularly those that are hard to change like eating healthier, being more physically active, stopping smoking. I think that’s where we do see an effect because even after the intervention is over, your friends are still your friends. Your family is definitely still your family. So those networks persist and therefore you see more promising data on effectiveness.”
Other factors that influence the effectiveness of financial incentives relate to plan design, says Wong. “With behavioral economics, it’s the design, framing, and delivery of that financial incentive that can make such a huge difference. Whether you’re giving someone $20, potentially taking $20 away from them, or putting them in a lottery to win $20, that type of design choice can influence the rates of motivation. Even though a standard economist would say we should all perform exactly the same because it’s $20 in each scenario, I think that type of nuance in how you design and deliver the financial incentive is a really critical point.”
The survey tally on the effectiveness of financial penalties for unhealthy behaviors (12%) is well down the list, indicating that most respondents think using penalties as a means of engaging patients in health goals is ineffective.
“The penalty has to be designed carefully,” suggests Wong. “When we’re offering any type of incentive program — reward or penalty — one of the major issues we see is there’s just very low consumer engagement.”
“The issue is engagement and education, because some people might not even know that they are either eligible for a reward or at risk of a penalty. It seems unfair to hit someone with a penalty when they’re not even aware of it, and I feel like our health care system is so opaque [in general] that it’s particularly challenging.”
Another concern with financial penalties is unintended consequences on vulnerable populations who already have challenges with equitable access to quality health care, says Namita Seth Mohta, MD, Clinical Editor at NEJM Catalyst, internal medicine physician at Brigham and Women’s Hospital, and faculty at The Center for Healthcare Delivery Sciences at Brigham and Women’s and at Harvard Medical School.
“We have to avoid inadvertently exacerbating health disparities and inequities with any type of improvement initiative. When we start considering penalties, for example a tax on sugary beverages, I do worry about disproportionate effects on people who are already marginalized,” she says.
The survey respondents consider financial rewards to be most effective in improving patient engagement for risk reduction, such as smoking cessation (56%), completing preventive screenings (49%), and promoting fitness and nutrition (35%).
“Some of the best evidence around the use of financial incentives is in the smoking cessation space,” says Wong. “That, along with completing preventive screenings, also has some of the most promising data. The use of incentives for one-time behaviors is generally more effective than the third item on the list — promoting fitness and nutrition — which is something that, if you really want it to work, you have to sustain it over a longer period of time.”
In summary, it’s important to use a combination of different initiatives, both financial and social, Wong says. “My personal feeling is that if you are able to combine two sources of influence, such as a financial incentive paired with something like social support, you’ll see a more robust and potentially more sustained effect.”
Mohta agrees, saying, “Pairing social programs with financial incentives makes sense. We should not be thinking about it as an either-or situation, but rather about how we can creatively do both to ensure that we’re getting effective, sustainable results that lead to better outcomes for our patients.”
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What is the most effective program or initiative your organization has used to improve patient engagement, and why was it successful?
“1. explanation from providers. 2. level of understanding of patients. 3. level of commitment of patients to follow what he or she understands. 4. we have enough tools to monitor improvement.”
“An engaging, persuasive, passionate, caring doctor is the only thing that will work. I think that paying your patients to do the behaviors that they should be doing anyway is a terrible idea – the only reason to offer rewards is so that you can decide who should NOT receive it. Period. That means you now have a toxic relationship with the patients you should not give it to, whether you decide directly or indirectly. It won’t change long term behaviors, and you will ruin a percentage of your patient relation.”
“Reduction in benefit costs for healthy behaviors like smoking cessation, colonoscopy, mammography, weight targets, etc.”
“Our hospitals are not interested in this unless they receive financial rewards or bonuses. There is no commitment to patient outcomes, only to improved reimbursement. We see this in over-treatment, over-testing and circular in-house referrals to hospital owned practices, and hospital owned service agencies like VNA. Frankly it’s awful and it is transparent and obvious.”
“Our clinic developed a food pharmacy, which dispenses healthy food by prescription from a physician to our patients with diabetes. It reduced the stigma of poverty, increased access to healthy foods, and improved knowledge about healthy eating. It is successful because of continued marketing to our patients, who are uninsured and food insecure.”
“Have RN level nurses answer the phone in my Primary Healthcare office for medical TRIAGE since they also managed the through-put process during office hours. After one to two years, the nurses almost knew everyone by name on the phone. Remember that the least skilled member of a Team determines its effectiveness.”
Download the full report for additional verbatim comments from Insights Council members.
Charts and Commentary
by NEJM Catalyst
We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about patient engagement incentives that do and don’t work. The survey explores the most effective approaches to engaging patients to realize health goals, sources of financial awards to realize health goals, sources of financial penalty when goals are not realized, effectiveness of financial rewards from various sources, activities for which financial rewards are the most effective, effectiveness of financial rewards and penalties to engage patients, and whether health care provider organizations should incentivize patients. Completed surveys from 607 respondents are included in the analysis.
Insights Council members indicate that family/friends support (35%) is the most effective approach in engaging patients in achieving health goals, likely because this approach offers the most sustainable benefit. Approaches such as financial rewards (27%), which can be effective in the short term, may lose their effectiveness once the rewards program ends.
While respondents say that health plans/payers/insurers (60%) and employers (41%) are the top sources of financial penalties, the level of response is 12 and 26 percentage points lower than with financial rewards, respectively, indicating that fewer of these organizations see value in penalties.
Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.