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Pennies for Pounds?

By Dr. Sujatha Prabhakaran

A frustration for many healthcare providers is patient noncompliance with prevention recommendations.  Since all of us are healthcare consumers as well as healthcare providers, our own lives can sometimes provide insight into the behaviors of our patients.  Physicians are notoriously guilty of neglecting their own health maintenance.  This is most likely because prevention behaviors have a cost and their benefit is remote from that cost.   In this case the cost is not always the direct monetary cost, but rather the time we must take out of our busy practices and lives to have testing that we won’t see the benefit of for years. 

Recently, arguments have been made that we need to provide immediate incentives for preventive behaviors to make compliance easier.  This practice is espoused by two behavioral economists in the book, Nudge.   Thaler and Sunstein argue that we are better at performing behaviors for which the positive incentive is immediate, for example, eating ice cream.  The benefit of eating ice cream is immediate and therefore it is an easy behavior to incentivize people to do.  In fact, people will pay to partake of this behavior.   On the other hand the benefit of abstaining from ice cream to lose weight is remote and therefore much more difficult.   They argue if we can move the reward for abstaining from ice cream closer to the time of they behavior, we can improve the chances of people engaging in the behavior. 

An example of this from the primary prevention setting is a study of financial weight loss incentives.  Patients given financial incentives for weight loss lost 12 more pounds after 16 weeks than the control group.  The incentives were: 1) being entered into a lottery each week if you lost a pound each week OR 2) patients put down money at the start of the program and if they met weight loss goals that money was matched and if not the money was forfeited.  Some of the weight lost was regained when subjects were reassessed at seven months, but the net effect was that the control group lost no weight from the start and the two intervention groups still had some net weight loss. 

Another option might be paying patients to have preventive testing.  While paying someone to have testing that is in their self interest can be hard to swallow, from the perspective of a health care system paying a woman to have her pap smear may be much less costly than treating cervical cancer down the road. 

Having a health care system that provides “carrots” for patients to incentivize preventive behaviors may be a much more effective than our current one that often offers only the “stick” of a guilt trip from your physician for not performing immediately costly behaviors.   

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