The ACP Advocate Blog
by Bob Doherty
Friday, February 27, 2009
Should we pay patients to stay healthy - and punish them if they don't?
Writing in the Wall Street Journal blog, Sarah Rubenstein reports that a new study finds that paying smokers to quit is effective and "succeeds far more often than those who got no cash reward."
There is a catch: "Most study participants were relatively well-educated whites with higher incomes, and it's possible the incentives might not work as well with other groups," Rubenstein notes, citing comments by Kevin Volpp, the study's lead researcher.
(The same research team found that paying obese people to lose weight also is effective, but that the results were not fully sustained over time.)
Some people advocate more punitive measures. The Happy Hospitalist, a regular commenter on the ACP Advocate Blog, says in his blog that smokers should get lower wages than non-smokers because "by decreasing a smoker's wage, you are making up for their increased consumption of benefits compared to non smokers. . . If you don't you are discriminating against non- smokers."
I understand the appeal of creating positive incentives for people to lose weight or stop smoking. But I am concerned about the consequences of reducing wages or cutting benefits to people who can't or won't stay healthy.
The West Virginia Medicaid program is being sued by a public interest law firm over a policy that cuts children's benefits when their parents don't sign a pledge to take steps to improve their kids' health, according to the Kaiser Daily Health Policy Report. The report observes that "ninety percent of West Virginia children enrolled in Medicaid have had their benefits reduced because their parents have not signed the pledge."
Is it right for children to get fewer health care benefits because their parents don't sign an agreement that promises to take them to the doctor for regular check ups and not use emergency rooms for routine visits?
The premise behind programs that reward people for healthful choices and punish them for bad ones is that their health is largely a product of choices, made freely by adults who should know better.
But is smoking really a choice, when we know that most smokers start as adolescents and nicotine is a highly addictive drug? Is being overweight just a bad choice, when we know that culture and upbringing, genes, lack of availability of healthful food in some lower-income communities, the super-sizing of portions, and marketing of fast food and soft drinks all play a role?
"Reward or punishment" programs may have the effect of widening health care disparities, because some cultural and ethnic groups and underserved populations - as in West Virginia - have much higher rates of smoking and obesity.
It is one thing for a well-off person to run down to the neighborhood gym, meet with their personal trainer, and pick up nutritious groceries at Whole Foods. They might like getting some extra cash in their pockets to reward them for their healthy "choices."
But what about people in the inner city or Appalachia, who don't have the same resources, education, literacy, and choices available to them?
Today's questions: Should patients be paid to quit smoking, lose weight, or other healthful behaviors? Should they be punished - higher premiums, lower wages, reduced benefits - if they don't?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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