In the Patient Engagement Survey: Why No Single Health Incentive Works from January 2019, financial rewards for healthy behaviors didn’t make the top three most effective approaches to engaging patients in order to realize health goals.
“I think it’s difficult to incentivize patients to do healthy behaviors because behavior change is complex, and it’s very difficult to figure out what to incentivize to promote behavior change,” says Ziad Gellad, MD, MPH, Associate Professor of Medicine at Duke University Medical Center and member of the Duke Margolis Center for Health Policy. “There are no quick fixes or magic pills.”
Financial incentives, while effective in the short term, are only good as long as the money holds out. Long-term sustainability of patient behavior change is tenuous at best with financial incentives because it isn’t always feasible to pay for healthy behaviors over a long period of time.
Gellad points out that the real challenge with behavior change is impacting patient motivation. “There’s an important distinction between intrinsic motivation and extrinsic motivation. My belief is that when people are intrinsically motivated for change, it’s much more effective change. That’s why financial incentives and penalties don’t work well at the individual level, because they aren’t really harnessing the intrinsic motivation.”
“People should want to quit smoking, for example, because it’s good for their health, they will feel better overall, it will be less expensive for them, and all the reasons why stopping smoking will be good for you,” he says. “Not because they’ll be charged an extra $10 on their insurance premium if they smoke.”
John Campbell, MD, FANPA, Chief Medical Informatics Officer and Director of Community Services at Northern Light Acadia Hospital in Bangor, Maine, is certified in psychiatry and neuropsychiatry. He says that most people use financial incentives to engage patients in behavior change because it is typically the first thing that comes to mind.
“I think that this is everybody’s first thought,” says Campbell. “Studies have shown it’s not necessarily the highest leverage approach, but it’s an important one. It’s called structural motivation; changing the patient’s economy.”
“Modest rewards can help with behavior change, but there are so many other sources of influence to change someone’s behavior. And it takes a lot to get people to give up their rituals, and patterns of thinking and behaving,” he says. “Financial incentives alone may work for certain individual patients, but if we bring this up to the level of population health, we’re not going to get the population as a whole healthier by solely offering financial motivation to engage in healthy behavior.”
Nithi S. Anand, MD, MPH, is a practicing neurologist at WellStar Medical Group, which is part of Georgia-based WellStar Health System. He acknowledges that financial incentives may have a role to play in shaping patient behavior, but cautions that the patient-provider relationship should be kept relatively clear of financial influences.
“Patients are not seeing a physician because they want to play the lottery or get a raffle ticket,” says Anand. “The whole point of trying to engage patients in their care is to make them intellectually buy in to their physician’s recommendations.”
Other factors impacting the effectiveness of financial incentives are the unique socioeconomic circumstances associated with each patient. For some patients, a $10 incentive or penalty looms far larger than for others.
“It depends on the size of the incentive and the patient’s individual context,” says Gellad. “It’s hard to know how effective a given financial incentive will be without also knowing about things like the patient’s health literacy, income, and general self-efficacy in terms of how empowered they are to impact their lives. All of this differs by individual. There may be individuals out there where $10 makes a big difference to them in terms of their families.”
The key to successfully impacting patient behavior is not relying on a single approach, but bringing multiple influences to bear.
“You have to engage multiple sources of influence, and that’s where we talk a lot about personalized care,” says Campbell. “Because there are two things that have to be done: You have to give up your current set of behaviors, which you do for many different reasons, and you have to substitute another set of behaviors, which is not easy to do. That’s why a single strategy alone based on their economy isn’t going to push an individual patient over the line.”
One approach that respondents in the survey almost universally reject is the use of financial penalties for unhealthy behaviors. Only 12% of respondents say that this approach is one of their top two for engaging patients in order to realize their health goals.
“Financial incentives tend to be limited to short-term impacts, but financial penalties are probably going to work in a negative way,” says Anand. “Engagement goes back to patient education, trusting your physician and your health system, and patients wanting to make a change. The use of penalties risks turning patients off, causing them to drop out of the program.”
Rather than using financial incentives and penalties directly, another strategy for changing patient behavior is to redesign the programs being used. Instead of paying patients for desired behaviors, organizations use their resources to remove the barriers that stand between the patient and a desired behavior.
“We can provide free gym memberships to individuals so that there are no barriers to exercise,” says Gellad, “rather than giving them $10 if they exercise.”
“A similar strategy is eliminating co-pays for colon cancer screenings or providing at-home screening tests free of charge,” he says. “In fact, there was a study recently reported in JAMA where individuals randomly assigned to a $10 incentive did not increase their FIT completion rates when compared to individuals mailed the kits without an incentive.”
Anand cites the employee health insurance program at WellStar Health as a good example of using reduced barriers to encourage more healthy patient behavior.
“Preventative care such as immunizations, yearly physical exams, and cancer screenings are free and included in our health system insurance plans,” says Anand. “As long as a patient’s out-of-pocket expenses are minimal, it promotes patient compliance and adherence.”
Note that the top result in our survey for most effective approaches to engaging patients in order to realize their health goals is family/friends support (35%), an indication of how powerful social influences are on patient behavior. But there are some challenges with implementing this type of approach, as well.
“I think you’re going to get more leverage with personal and social motivations,” says Campbell. “But they take longer and they’re more complex. It’s pretty easy to just lay down a financial reward than it is, for example, to ask a patient to bring in their spouse or other family member to have a discussion about their weight and eating habits.”
An even bigger question for health care providers to consider is whether health care provider organizations should be involved in incentivizing patients to improve health behaviors to begin with, or is this mainly the realm of insurers and employers? The majority of survey respondents (59%) respond in the affirmative, but there are concerns about the sanctity of the provider-patient relationship.
“I don’t think that providers should incentivize patients directly,” says Gellad. “I think that this gets in between the patient-provider relationship, and I believe that we should try to maintain that as a sacred relationship and not have financial incentives get in the way.”
“However, I think provider organizations should make it easier for patients to engage in healthy behaviors by providing lower-cost access to services. There are lots of different ways to leverage resources to incentivize good healthy behavior that don’t involve directly writing a check for good behavior,” he says.