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Incentives in workplace wellness programmes
Comment
Wellness programmes have become a primary way that employers aim to prevent obesity, diabetes, and other lifestyle diseases among their workers. Employers have spent generously on these programmes, lured not only by the potential health gains but also by the potential for a more productive and happier workforce. Employers in the USA, where most health insurance is obtained through employment, have also turned to wellness programmes to control medical costs and health insurance premiums. One increasingly popular component of wellness programmes is the use of monetary incentives to reward or penalise workers for participating in wellness activities or achieving particular health outcomes. By 2015, more than half of large employers in the USA offered incentives through a wellness programme.1,2 Wellness incentives have flourished as programmes have expanded their measurement of outcomes through health risk assessments and biometric screening. Incentives have been conditioned on biometric outcomes such as body mass index, blood pressure, cholesterol, and glucose.1 Government action has also facilitated the spread of incentives. For example, the US Affordable Care Act of 2010 increased the amount of incentive or penalty that an employer or plan may impose from 20% of a person’s total premium to 30% (or 50% for smoking cessation). Regrettably, such programmes have flourished despite a limited amount of high-quality evidence. Some studies3–5 have found that wellness programmes in general promote participant engagement and health improvements and reduce health costs, although many lack rigorous designs and credible data. Moreover, few studies explicitly examine the effects of incentives—only two of 33 studies according to one review.4 In a study reported earlier this year,6 Mitesh Patel and colleagues randomly assigned 200 participants with obesity from a single organisation to either receive no incentive, an insurance premium discount of US$550 beginning either the following year (delayed condition) or in the first period after meeting the weight target (immediate condition) in exchange for meeting a weight loss target, or a daily lottery of $10 (18% chance) or $100 (1% chance) for meeting a weight loss target on the previous day. All participants were given a weight loss target of 5% of their baseline weight. None of
the incentive regimes significantly increased weight loss after 6 or 12 months, although the lottery did substantially increase participant engagement. The study’s null findings raise important questions about how to design incentives for wellness programmes, notably because of the incorporation in the study of several promising insights from the burgeoning field of behavioural economics. Traditionally, wellness incentives have been viewed either as subsidies to overcome economic barriers such as the cost of a gym membership or as enticements to attract participants. Research from behavioural economics has fostered an understanding of how incentives can also address psychological barriers to healthy behaviour. These are decision errors that prevent people from making healthy choices, such as a tendency to disproportionately favour immediate benefits over future benefits. Informed by behavioural economics, other researchers have shown several different wellness incentive designs that help individuals to overcome decision errors. One approach is a “regret” lottery, in which participants are notified whether they would have won if they had achieved some pre-specified target, thereby exploiting feelings of anticipated regret. Regret lotteries have been successfully used to promote weight loss and health risk assessment completion.7,8 Another approach is a deposit contract, in which individuals essentially “bet” that they will achieve some goal, thereby exploiting over-optimism about self-control and aversion to loss. Deposit contracts tend to limit participation by selecting for motivated participants who are aware of their self-control problems, but have proven effective for weight loss, smoking cessation, and other behaviours.7,9 A third approach is the use of group-based incentives, which can be designed to encourage competition, collaboration, or social pressure. Group-based incentives have outperformed individual incentives in some cases.10 Behavioural economics studies11 have also shown that incentives are more effective when awarded closer to the targeted behaviour—eg, daily rather than monthly—and when made more salient. In Patel and colleagues’ study,6 the incentives were bundled with relatively larger insurance premiums, probably dampening their effect. This has crucial implications for wellness programme
www.thelancet.com/diabetes-endocrinology Published online August 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)30186-3
Adrian Weinbrecht, Cultura /Science Photo Library
Incentives in workplace wellness programmes
Lancet Diabetes Endocrinol 2016 Published Online August 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)30186-3
1
Comment
design, given how commonly incentives are awarded as premium adjustments. Collectively, research from behavioural economics has highlighted how design features such as an incentive’s timing, salience, and framing can matter a great deal for the effectiveness of a wellness programme. However, there remains a broader set of challenges for wellness incentives. First, few studies document clinically meaningful, sustained behaviour change, with notable exceptions.9 Once the novelty and motivating power of an incentive scheme fades, participants often return to their pre-intervention behaviour. Researchers are currently testing a variety of approaches for long-term maintenance of healthy behaviour, including phasing in different incentives over time, escalating rewards, and game-based designs to engage participants in the long term. Second, there is insufficient evidence on how health-contingent incentives differentially affect heavy users of medical care and other vulnerable populations, who may be less likely to select into wellness programmes and less able to meet the criteria for earning incentives.12 Overall, additional rigorous evaluations are needed to guide a large and growing wellness industry on how best to leverage incentives for health promotion.
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Justin S White Philip R Lee Institute for Health Policy Studies, University of California, San Francisco, CA 94118, USA [email protected] I declare no competing interests. This work is supported by the US National Institute on Drug Abuse (award R01DA035384). 1
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Claxton G, Rae M, Long M, Panchal N, Damico A. Employer health benefits: 2015 annual survey. Menlo Park, CA: The Kaiser Family Foundation and Health Research and Educational Trust, 2015. Towers Watson. The new health care imperative: driving performance, connecting to value. New York, NY: 2014. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Affairs 2010; 29: 304–11. Osilla KC, Larkin JW, Eibner C, Mattke S. Systematic review of the impact of worksite wellness programs. Am J Manag Care 2012; 18: e68–e81. Mitchell MS, Goodman JM, Alter DA, et al. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med 2013; 45: 658–67. Patel MS, Asch DA, Troxel AB, et al. Premium-based financial incentives did not promote workplace weight loss in a 2013–15 study. Health Aff 2016; 35: 71–79. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA 2008; 300: 2631–37. Haisley E, Volpp KG, Pellathy T, Loewenstein G. The impact of alternative incentive schemes on completion of health risk assessments. Am J Health Promot 2012; 26: 184–88. Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med 2015; 372: 2108–17. Kullgren JT, Troxel AB, Loewenstein G, et al. Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial. Ann Intern Med 2013; 158: 505–14. Chetty R, Looney A, Kroft K. Salience and taxation: theory and evidence. Am Econ Rev 2009; 99: 1145–77. Horwitz JR, Kelly BD, DiNardo JE. Wellness incentives in the workplace: cost savings through cost shifting to unhealthy workers. Health Aff 2013; 32: 468–76.
www.thelancet.com/diabetes-endocrinology Published online August 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)30186-3
Wellness programmes have become a primary way that employers aim to prevent obesity, diabetes, and other lifestyle diseases among their workers. Employers have spent generously on these programmes, lured not only by the potential health gains but also by the potential for a more productive and happier workforce. Employers in the USA, where most health insurance is obtained through employment, have also turned to wellness programmes to control medical costs and health insurance premiums. One increasingly popular component of wellness programmes is the use of monetary incentives to reward or penalise workers for participating in wellness activities or achieving particular health outcomes. By 2015, more than half of large employers in the USA offered incentives through a wellness programme.1,2 Wellness incentives have flourished as programmes have expanded their measurement of outcomes through health risk assessments and biometric screening. Incentives have been conditioned on biometric outcomes such as body mass index, blood pressure, cholesterol, and glucose.1 Government action has also facilitated the spread of incentives. For example, the US Affordable Care Act of 2010 increased the amount of incentive or penalty that an employer or plan may impose from 20% of a person’s total premium to 30% (or 50% for smoking cessation). Regrettably, such programmes have flourished despite a limited amount of high-quality evidence. Some studies3–5 have found that wellness programmes in general promote participant engagement and health improvements and reduce health costs, although many lack rigorous designs and credible data. Moreover, few studies explicitly examine the effects of incentives—only two of 33 studies according to one review.4 In a study reported earlier this year,6 Mitesh Patel and colleagues randomly assigned 200 participants with obesity from a single organisation to either receive no incentive, an insurance premium discount of US$550 beginning either the following year (delayed condition) or in the first period after meeting the weight target (immediate condition) in exchange for meeting a weight loss target, or a daily lottery of $10 (18% chance) or $100 (1% chance) for meeting a weight loss target on the previous day. All participants were given a weight loss target of 5% of their baseline weight. None of
the incentive regimes significantly increased weight loss after 6 or 12 months, although the lottery did substantially increase participant engagement. The study’s null findings raise important questions about how to design incentives for wellness programmes, notably because of the incorporation in the study of several promising insights from the burgeoning field of behavioural economics. Traditionally, wellness incentives have been viewed either as subsidies to overcome economic barriers such as the cost of a gym membership or as enticements to attract participants. Research from behavioural economics has fostered an understanding of how incentives can also address psychological barriers to healthy behaviour. These are decision errors that prevent people from making healthy choices, such as a tendency to disproportionately favour immediate benefits over future benefits. Informed by behavioural economics, other researchers have shown several different wellness incentive designs that help individuals to overcome decision errors. One approach is a “regret” lottery, in which participants are notified whether they would have won if they had achieved some pre-specified target, thereby exploiting feelings of anticipated regret. Regret lotteries have been successfully used to promote weight loss and health risk assessment completion.7,8 Another approach is a deposit contract, in which individuals essentially “bet” that they will achieve some goal, thereby exploiting over-optimism about self-control and aversion to loss. Deposit contracts tend to limit participation by selecting for motivated participants who are aware of their self-control problems, but have proven effective for weight loss, smoking cessation, and other behaviours.7,9 A third approach is the use of group-based incentives, which can be designed to encourage competition, collaboration, or social pressure. Group-based incentives have outperformed individual incentives in some cases.10 Behavioural economics studies11 have also shown that incentives are more effective when awarded closer to the targeted behaviour—eg, daily rather than monthly—and when made more salient. In Patel and colleagues’ study,6 the incentives were bundled with relatively larger insurance premiums, probably dampening their effect. This has crucial implications for wellness programme
www.thelancet.com/diabetes-endocrinology Published online August 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)30186-3
Adrian Weinbrecht, Cultura /Science Photo Library
Incentives in workplace wellness programmes
Lancet Diabetes Endocrinol 2016 Published Online August 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)30186-3
1
Comment
design, given how commonly incentives are awarded as premium adjustments. Collectively, research from behavioural economics has highlighted how design features such as an incentive’s timing, salience, and framing can matter a great deal for the effectiveness of a wellness programme. However, there remains a broader set of challenges for wellness incentives. First, few studies document clinically meaningful, sustained behaviour change, with notable exceptions.9 Once the novelty and motivating power of an incentive scheme fades, participants often return to their pre-intervention behaviour. Researchers are currently testing a variety of approaches for long-term maintenance of healthy behaviour, including phasing in different incentives over time, escalating rewards, and game-based designs to engage participants in the long term. Second, there is insufficient evidence on how health-contingent incentives differentially affect heavy users of medical care and other vulnerable populations, who may be less likely to select into wellness programmes and less able to meet the criteria for earning incentives.12 Overall, additional rigorous evaluations are needed to guide a large and growing wellness industry on how best to leverage incentives for health promotion.
2
Justin S White Philip R Lee Institute for Health Policy Studies, University of California, San Francisco, CA 94118, USA [email protected] I declare no competing interests. This work is supported by the US National Institute on Drug Abuse (award R01DA035384). 1
2 3 4 5
6
7
8
9
10
11 12
Claxton G, Rae M, Long M, Panchal N, Damico A. Employer health benefits: 2015 annual survey. Menlo Park, CA: The Kaiser Family Foundation and Health Research and Educational Trust, 2015. Towers Watson. The new health care imperative: driving performance, connecting to value. New York, NY: 2014. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Affairs 2010; 29: 304–11. Osilla KC, Larkin JW, Eibner C, Mattke S. Systematic review of the impact of worksite wellness programs. Am J Manag Care 2012; 18: e68–e81. Mitchell MS, Goodman JM, Alter DA, et al. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med 2013; 45: 658–67. Patel MS, Asch DA, Troxel AB, et al. Premium-based financial incentives did not promote workplace weight loss in a 2013–15 study. Health Aff 2016; 35: 71–79. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA 2008; 300: 2631–37. Haisley E, Volpp KG, Pellathy T, Loewenstein G. The impact of alternative incentive schemes on completion of health risk assessments. Am J Health Promot 2012; 26: 184–88. Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med 2015; 372: 2108–17. Kullgren JT, Troxel AB, Loewenstein G, et al. Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial. Ann Intern Med 2013; 158: 505–14. Chetty R, Looney A, Kroft K. Salience and taxation: theory and evidence. Am Econ Rev 2009; 99: 1145–77. Horwitz JR, Kelly BD, DiNardo JE. Wellness incentives in the workplace: cost savings through cost shifting to unhealthy workers. Health Aff 2013; 32: 468–76.
www.thelancet.com/diabetes-endocrinology Published online August 8, 2016 http://dx.doi.org/10.1016/S2213-8587(16)30186-3