Next-Generation Incentives: Interactive Engagement Promotes Healthy Behavior

Wellness incentives won't work if they target people in the wrong way

By Greg Goth Jun 6, 2017
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We are on the cusp of a new era in health care communication, believes Kevin Volpp, M.D., a pioneer in researching how people respond to efforts to engage them in achieving better health.

"We're at Engagement 2.0," Volpp said. "We now know a lot more about what motivates people and how that helps to get them engaged and stay engaged."

If Engagement 1.0 was the standard way companies would interact with employees by "maybe adjusting their benefits or premiums a bit as a way to engage them," there is now "a world of new possibilities that are extremely exciting, with a lot of yet-unrealized opportunity," noted Volpp, the director of the Center for Health Incentives & Behavioral Economics at the University of Pennsylvania. One of his projects was an intervention study on smoking cessation at General Electric (GE). The program structured incentives as follows:

  • $100 for completing a smoking-cessation program.

  • $250 for being able to demonstrate (via a biochemical test) a cigarette-free lifestyle after six months.

  • $400 for remaining cigarette-free for the following six months.

Only those who quit smoking in the first six months were eligible for the $400 incentive.

At the same time, GE introduced a smoking-cessation program that consisted of education about the harmful effects of smoking and links to community programs. All employees, whether study participants or not, had a benefits package that covered tobacco-cessation pharmaceuticals.

The result of the study: Incentivized participants gave up smoking at three times the rate of their nonincentivized peers.

Incentivized participants gave up smoking at three times the rate of their nonincentivized peers.

Unlike many other incentive programs, GE paid out the incentive in increments over a full year, "requiring participants to modify their behavior over a relatively long period of time, so that restraining from smoking became routine," Volpp explained. Studies with quick payouts for short-term accomplishments have tended to show high rates of recidivism following the payout. 

The GE program also reduced procrastination by only making employees eligible for the largest incentive—$400—if they quit smoking in the first six months following enrollment in the study.

Like Volpp's study on the GE program, new research into incentive designs is now "going live" in corporate wellness programs that stress personalized engagement and incentivizing employees to take greater responsibility for their health outcomes.

Incremental Incentives

"We've learned a lot over the years about using incentives more judiciously to benefit both participants and employers," said David Anderson, co-founder and adviser at StayWell, a Yardley, Penn.-based wellness program provider.

According to the firm's recent report, The Changing Tide of Health Care and Wellness Incentives, an alternative to incentives for participation or for goal-achievement is a progress-based incentive model that lets employees earn rewards in increments as they approach their health goals. "This provides an achievable alternative for individuals across the health continuum," Anderson said. As opposed to an outcomes-based model, progress-based incentives "may be viewed more positively by individuals for whom the ideal goal does not seem achievable."

Behavioral Economics a Linchpin

Matt Loper, co-founder and CEO of Wellth, a new mobile platform that encourages people to take prescription drugs on time (i.e., medication adherence), explained the growing emphasis on behavioral economics when designing incentive programs.

"One of the basic assumptions of traditional economics is that people act rationally in their own interests," Loper said, "but 50 percent of people with chronic disease are nonadherent in their medication regimens."

"Present bias" contributes to behavior that does not jibe with beneficial self-interest, Loper explained.

"Our human psychology is only meant to be motivated by immediate-term gratification," he said. "In terms of medication adherence, people know they are supposed to take these meds, but they don't feel any different right now by not taking it. Likewise, they know they shouldn't eat that candy bar sitting on the table, but eating it makes them feel good right now."

To encourage people to take their medications, companies use reminders or present employees with data about the long-term effects on their health, "but they don't solve the core issue of present bias," Loper said.

Wellth, currently in late-stage trial mode, gives patients a $150 credit (usually funded by an insurer) and a smartphone-based platform. It works this way:

  • A push notification reminds recipients that it's time to take their medication.

  • When the patient swipes the notification, the phone automatically opens a camera app.

  • The patient takes a photo of the medication in their hand and saves it to the platform.

Every time patients take their medication, they keep a small portion of the deposited money. "If you don't take the picture, you lose $2" out of the credited funds, Loper said. "We do that every day for 90 days so it forms a habit that sticks."

[SHRM members-only toolkit: Designing and Managing Wellness Programs]

Beyond Health Warnings

Wellness promotion needs to go beyond sending diagnostic cautions to employees, agreed Joel Spoonheim, director of health promotion for HealthPartners, which runs a network of Minneapolis-based health clinics.

"We shouldn't be saying, 'Hey, you are on track for this condition'; we should be saying, 'What motivates you to be healthy and how can we support you?' " he said.

Technology can help support that dialogue, and HealthPartners' clinics have partnered with Denver-based tech firm Welltok to create and deliver more-personalized patient engagement.

An example is the approach toward smoking cessation. "If a person who smokes is only told 'quit smoking' and they are not ready, you have alienated them," said Spoonheim. "But if you know they are not ready to quit smoking but have a high willingness to talk about stress, and put that up first, it's now a meaningful personalized relationship."

Added Ari Levy, M.D., founder of SHIFT Sciences, a Chicago startup that offers integrated primary care and fitness-promotion services, "What the most successful technology platforms have done is less about any carrot or stick. It is more about making it easy for humans to just connect. Each one of our members signs a release agreeing to communicate by e-mail, text and phone [which are not secure communications under the Health Information Portability and Accountability Act] because they want to be connected" with the firm's health providers and coaches.

Health, Not Health Care, Is the Goal

In assessing new collaborative apps that foster interactive approaches, benefit managers should keep these tips in mind:

  • Targeting high-cost conditions may not pay off. Adverse social factors sometimes deter employees with health challenges from changing their habits: "If you pick a population that is very high risk for chronic conditions and you are unsuccessful in changing their behavior, you haven't accomplished a whole lot," Volpp said. "The sweet spot is the intersection between those at high risk and those amenable to solutions that are being offered," such as interactive communications and personalized engagement.

  • Reassess where incentives are applied. "Incentives have often been misapplied," Loper said. For instance, giving away rewards for gym membership, especially without any evidence of whether the gym is actually being used, "won't change anything in the way of [reducing health care] utilization, and certainly not within the next five years," even if the recipient is working out. But very simple behaviors like making sure patients take their medication every single day after a heart attack will produce significant changes in utilization, even within the next 30 or 90 days."

  • Consider the whole person. "It takes time to get to know a human being, not only from the physical ailments they have but who they are as an individual," Levy said. Technology and communications platforms can play an important role, but they should support the work of health coaches, not supplant it. 

"Everybody has a story, and you have to spend time building a relationship to understand it," he said.

Greg Goth is a freelance health and technology writer based in Oakville, Conn.

Related SHRM Articles:

Best Practices for Using Wearable Devices in Wellness Programs, SHRM Online Benefits, May 2017

EEOC Settlement of Wellness Suit Leaves Unresolved Issues, SHRM Online Benefits, April 2017

Employee Loses Wellness Plan Challenge, SHRM Online Employment Law, February 2017

IRS Reminds Employers: Wellness Incentives Are Taxable, SHRM Online Benefits, July 2016

Related Resource:

Incentives for Workplace Wellness Programs, RAND Research Brief, 2015

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