Carrots and sticks to promote a healthy lifestyle?

When it comes to deciding whether paying people to make healthier lifestyle changes is a good thing, it seems patient opinion is split right down the middle.

Unsurprisingly perhaps, those who smoke and are overweight are its greatest advocates. This is the finding of a study1 by Judith Long and her colleagues from the University of Pennsylvania School of Medicine to be published in the October issue of the Springer publication, Journal of General Internal Medicine.

In an effort to stem the tide of rising healthcare costs, 'Pay for Performance for Patients' (P4P4P) schemes have been gaining popularity in the US and worldwide. The theory goes that the modest payments to patients are more than made up for by long-term savings in healthcare costs if the payments result in lifestyle changes, such as giving up smoking or maintaining a lower body weight. Much of the argument against them revolves around this very point – whether these payments actually do result in a change in behavior. Studies thus far have been mixed with some showing no improvement in care or outcome and others being relatively successful.

Long and colleagues conducted a survey of 515 patients in waiting rooms in primary care practices. In this first survey of patient opinion of P4P4P, they found the respondents were split almost 50/50 as to whether it was a good or bad idea. Overall, smokers and obese individuals thought that paying for lifestyle change was a good idea, that it would lower everyone's healthcare costs and that it may be the only effective way to bring about lifestyle change. The authors attribute this to their difficulties in the past trying to change the behavior in question whereas individuals without these problems have no idea of the difficulties involved and cannot therefore see the point of incentives.

In addition, the authors found the responses received to some questions were very much based on how the questions were worded. For example, when questioned about health insurance and P4P4P, all respondents were keen on incentives which rewarded individuals for good health behavior but not keen on those that were seen as punishments, e.g. they thought it was a good idea to give lower premiums to non-smokers but not to charge higher premiums to smokers in an effort to get them to stop smoking. In effect, this is one and the same thing but this finding has dramatic consequences for the planning of future initiatives.

This unique survey therefore has important implications for companies thinking about financial incentives for healthy behaviors as well as insurers and policy makers considering its widespread use. The authors conclude that 'given the prevalence of unhealthy behaviors in the US population, serious consideration needs to be given to any approach that may effectively motivate improvements in the rate of healthy behavior.' For the moment, further evidence of effectiveness and cost effectiveness is required as this may lead to wider support for these programs and their efficient targeting.