Financial incentives could encourage people to adopt healthier lifestyles – and save billions in healthcare costs in the process, writes ELEANOR FITZSIMONS
HEALTH AUTHORITIES, increasingly aware that the unhealthy behaviour of citizens can add considerably to the healthcare bill, are scrambling to find workable solutions.
In particular, the global rise in obesity, a key factor underlying many chronic diseases, has placed that costly condition at the top of the public health policy agenda. The World Health Organisation has determined that obesity accounts for up to 8 per cent of all health costs and between 10 and 13 per cent of deaths in Europe.
Ireland comes second behind the UK in the OECD European league table of overweight nations, and our incidence of obesity has climbed by 40 per cent in 10 years. In order to tackle this and other health issues, some national health services are considering the introduction of financial incentives to encourage people to adopt a healthier lifestyle.
While such schemes have not been explored to any great extent here, they are being evaluated in the UK, the US and several other jurisdictions. In the UK, a comprehensive independent review of healthcare funding completed in 2002 concluded that for the NHS to be truly viable individuals need to take greater responsibility for their own health. This resulted in the publication of a 2004 white paper, entitled Choosing Health, which explored the option of incentivising people to pursue healthy behaviour.
The UK National Obesity Strategy suggests that financial incentives might promote healthy eating, physical activity and consequent weight loss. The National Institute for Health and Clinical Excellence (NICE), an organisation that previously recommended incentivising drug users to co-operate with drug-cessation programmes, agrees.
Smoking represents another obvious target. Last year, UK authorities implemented a pilot scheme designed to encourage pregnant women to quit. The Stop Smoking Service offers vouchers for high street shops to a value of £150 (€176) if a woman abstains from smoking during her pregnancy and for two months after the baby’s birth. In Dundee, a similar scheme targets the city’s 36,000 smokers and offers them food vouchers worth £12.50 (€14.72) per week if they kick the habit.
In September, the US Senate voted to adopt measures designed to reward healthy behaviour as part of the Obama administration’s overall healthcare reform. At the same time Circulation, the journal of the American Heart Association, reported that US companies could reduce health costs and boost productivity if risk factors for heart disease were addressed.
It is estimated that 25-30 per cent of a company’s annual medical expenditure goes on employees with obesity, high blood pressure, high cholesterol and diabetes. Companies such as Virgin HealthMiles and RedBrick Health have developed “pay for prevention schemes” on behalf of major corporations.
So how effective are such schemes? The King’s Fund, an independent charitable foundation working to improve the health system in England, has evaluated the evidence.
In her report, Paying the Patient: Improving Health using Financial Incentives, Dr Karen Jochelson, a research fellow in policy at the King’s Fund, concluded that while these schemes are easy to implement, they are only effective when the desired outcome is straightforward and short term.
One good example is a pilot scheme operating in Birmingham and offering vouchers worth £45 (€53) to 16-18 year old girls who agree to receive the HPV vaccination administered to prevent cervical cancer. Preliminary results indicate a 20 per cent higher take-up rate as a result.
These short-term interventions are designed to either encourage healthy behaviour such as attending clinic appointments, receiving vaccinations or break habitual patterns of damaging behaviour. The hope is that once good behaviour is established, it will prove to be resilient.
However, schemes may prove less effective in situations where long-term behavioural changes, such as sustained weight loss, are required. Furthermore, medical practitioners mustn’t lose sight of their true goal. One US scheme paid young girls to attend sexual health classes, but no consequent decrease in the rates of sexually transmitted infections was observed.
Implementation of successful schemes may bring great rewards. Weight Wins, the company running a pilot incentivised weight-loss scheme in Kent, in the UK, calculates that the NHS could save £1.7 billion in lifetime medical expenses per million citizens taking part. A similar outcome could net our Exchequer savings of almost €2 billion.
The approach taken here is broadly in line with an OECD health policy finding that governments “act as a balanced and authoritative source of information, thus providing clear guidance to individuals who struggle to cope with increasingly powerful environmental influences”. Examples include initiatives such as giveupsmoking.ie and littlesteps.eu.
Perhaps the most effective schemes use a combination of different approaches. Mercy Health Plan in Philadelphia increased childhood immunisation by rewarding compliant parents with a $10 (€7.30) voucher. However, the reward was offered as part of a comprehensive programme that included home visits by registered nurses and ongoing education.
In Ireland, schemes such as the Food Dudes (fooddudes.ie) programme encourage primary school children to eat fruit and vegetables every day, rewarding them with small toys. It also promotes positive role models and offers children the opportunity to taste healthy food.
Pilot studies were deemed effective in stimulating long-lasting behavioural change among primary school children, regardless of socio-economic or other factors. Rather than simply pay for healthy behaviour, perhaps this more considered approach is the one to adopt.
Getting paid to stay healthy
In America, a scheme offering a $10 (€7.30) payment increased clinic attendance among patients with depression from 69 per cent to 86 per cent.
Attendance at a tuberculosis clinic increased from 33 per cent to 93 per cent among active drug users when a $5 (€3.60) incentive was offered.
Completion of a course of hepatitis vaccinations among homeless men increased from 23 per cent to 69 per cent when they received $20 (€14.60) per month for six months of treatment.
Child immunisations increased fourfold when parents were offered a lottery ticket. Under a similar scheme, take-up of flu immunisations increased by almost 50 per cent.
The completion of tuberculosis treatment in Russia, Eastern Europe and Latin America was also incentivised via cash, transport vouchers and food hampers.
