Pay Patients Without Overpaying

If you want physicians as a group to focus more on quality, pay them based on performance. If you want employees to quit smoking or follow routine wellness programs, give them cash incentives. If you want to remind patients to take their medication, pay them with a lottery.

Sometimes it seems that paying cash is the only way to get anyone to do anything, even when inaction is potentially life threatening.

The New York Times has an interesting profile this week of an Aetna-sponsored program in Philadelphia that paid patients who had been prescribed warfarin for remembering to take their medication. A computerized pillbox recorded whether or not patients took the correct dosage each day and awarded a $10 or $100 lottery payment to those who did.

And for some patients, it really worked. One patient said the lottery was like a game and made him look forward to taking his medication, and another went back to forgetting to take her pills, or incorrectly taking two a day, when the lottery ended.

It is discouraging to discover that saying, "It will improve your health or possibly save your life," isn't enough to convince a lot of patients to comply with medication instructions or live a healthier lifestyle. But if words alone were enough to change ingrained behaviors, health problems would be a lot easier to solve.

There are many cases where paying patients (or even providers and others involved in healthcare) not only works, but it is a good investment. Between one-third and one-half of all patients don't take prescriptions as prescribed, costing up to $100 billion annually when some of those patients get sicker and end up in the hospital, according to the Times.

The $90-a-month that patients received on the warfarin study will pay for itself if it prevents just two emergency clinic visits, said the University of Pennsylvania Medical School professors who led the project.

But that doesn't mean that throwing cash around is the way to solve every health problem.

In fact, a recent study found that financial incentives weren't as important as "internal motivators" when it came to participating in certain employer wellness programs. The National Business Group on Health and Hewitt Associates surveyed 3,000 employees about their participation in employer-sponsored wellness activities, and found that many were ready and willing to participate. As an example, 48% said they would fill out a healthcare questionnaire because "it was the right thing to do," and only about 28% said they would do it because of financial rewards or penalties.

So while paying patients to improve their own health works sometimes, it isn't always necessary. The challenge for payers and employers is to figure out when it is appropriate, and at what levels, so they can achieve change without overpaying. Paying patients $90 to take their warfarin worked just as well as paying them $150, which is important to know if you're looking at rolling out a project over a large patient population.

As one member of Hewitt Associates put it when talking about the wellness study, "[You] don't have to pay people to do everything. It may be better to just pay for the things that are harder to do."