So, in contract, what will happen if the patients and physicians are given money? Gaining money works as a strong incentive to promote the targeted behaviors, as many studies show. Can a physician improve the performance of clinical work for a better salary? And does a patient make more efforts to lose his weight for getting a reward?
Recently, this fundamental question was examined in a sophisticated way.
JAMA: Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels
A Randomized Clinical Trial
The authors conducted a randomized controlled trial to examine the effect of financial rewarding in the clinical work to reduce LDL cholesterol. LDL cholesterol should be controlled to maintain physical health. Remaining LDL cholesterol at a high level becomes a risk of a cardiovascular event such as myocardial infarction. Patients having such risks were chosen as the participants for this study.
In this trial, physicians were assigned to one of the four groups: patient-incentive, physician-incentive, shared-incentive, or control. Physicians in the incentive group were rewarded if their patient achieved the targeted level of LDL cholesterol. On the other hand, patients in the incentive group occasionally got money if they took the daily pills regularly. In the shared-incentive group, the amount of each reward was halved to distribute it to the physician and the patient.
As a result, only shared-incentive group accomplished in maintaining the LDL cholesterol of the patients at a lower level than other groups with statistical significance. Surprisingly, the mean value of the reduction in LDL cholesterol in the patient-incentive group was almost the same as a control group.
This study is highly well structured. Since physicians were randomly assigned to either group, there look no differences between groups in several elements of the participants potentially confounding the effect of incentives. For example, rich patients can be indifferent to the small amount of reward. Highly educated patients may have a better understanding about the incentive. Such factors are proven not to have interfered the result of this study.
Additionally, patients in the incentive groups were given an intermittent reinforcement with a lottery system. They got money after taking pills with a certain possibility. It is well known that immediate rewarding maximize the effect to promote the preceding behavior. On the contrary, delayed rewarding is not so effective for reinforcing a particular behavior. If they had been rewarded only annually, they would not have been reinforced correctly. Furthermore, intermittent rewarding is believed to be more powerful than regular rewarding, as you know that gambling is so attractive.
The patient-incentive group received no benefit from the incentive in the reduction of LDL cholesterol. But a post-hoc analysis revealed that daily lotteries for medication adherence were effective only in patients having been taking medication at the baseline. Chronically medicated patients may need some incentives to enhance their motivation for daily taking pills.
The authors concluded the effectiveness of shared incentive for patients and physicians. But I think these results show it is likely that a simplified financial incentive is not beneficial in the health matter. Indeed, there have already been several schemes to promote the public health. If it were effective, there would not be obese people.
It remains a question why this kind of incentive for patients was not effective. Physicians may not be fascinated in the reward because they had already earned enough money. But how about the patients?
I imagined a study in which two groups were compared. In this study, participants in the control group are encouraged to take a task not relevant to their health status (i.e. taking an explicit placebo every morning) for the reward. With believing the authors' assumption, their vain behavior should be reinforced. Thus, taking pills regularly is specifically difficult to maintain for patients, even comparing with a meaningless behavior. Interesting.