I’ve written often about how the use of financial incentives could result in unfair cost shifting, victim blaming, and generally evoking more harm than good. In 1992 I wrote the first of many articles on the foibles of “risk-rating” — what is now, errantly, referred to as “outcomes-based incentives.” I take no satisfaction in having foretold the dark side of incentives, given how poised the health promotion field seems to be for rapid learning in the smart use of incentives. Given maturation finally seems afoot, I find myself at odds with my respected editor, Dean Witherspoon, who pans incentives as “bribes and coercion.” In a recent issue of Well-Being Practitioner, Dean’s article on a “common sense” well-being model held that “you really don’t care who or how many people sign up for your wellness program.” That makes little sense to me.

Though I stand by my cautionary articles about traversing the ethical slippery slopes where incentives precariously perch, Dean’s preoccupation with the taint of bathwater makes me fretful about the baby. Indeed, having witnessed the prolonged infant stages of incentives, I find the latest research and web-based innovations all the more promising. Check out Plus3 Network1, because if “bribes” lead to extraordinary philanthropy, count me in! At Plus3 you’ll seen an incentive program that plays to our altruism gene. Just $8/month has been shown to spark sustainable engagement. If you don’t care that the Plus3 app produced 72 billion steps, how about the fact that it also moved $1,780,124 to charities the app users care about?

Cultural context matters when it comes to how we react to financial penalties or rewards. I’ve studied irrational choice theories, but my brain lit up nonetheless when I joined millions of other dopamine-charged Americans and paid $2 to win the billion dollar lottery. I didn’t win, but I’m certain it was a near miss. It did not surprise me when research showed that lottery-based financial incentives for wellness worked better for low-income workers. Las Vegas exists for reasons we can learn from and it makes sense to me to translate those reasons into good. Visit Stickk.com2 for a fascinating, albeit gambling-like approach to using incentives within the context of well researched behavioral economic principles. On the Stickk site you’ll learn about “deposit contracting.” It’s a “skin in the game” approach that impresses me as decidedly more persuasive than the usual “do this to get that” attainment incentives.

Are video gamers coerced into the thousands of hours of immersion into virtual worlds they love?  Perhaps, but watch Jane McGonigal’s wildly popular Ted Talk on applying game theory to solving social problems before you throw out the bathwater that’s commonly ascribed to the game community.

Even though science remains formative per the effective use of incentives, I’m certainly swayed by those testing and applying what we know so far. Type Kevin Volpp3 into a PubMed search and scroll through the last 50 of his 134 research articles. The titles alone should impress upon you that serious scientists care deeply about whether incentives can attract marginalized groups into wellness activities and support greater success at behavior change. One of Volpp’s randomized controlled studies is available as an open access PDF from The New England Journal of Medicine.4 Volpp and colleagues care about how many sign up for programs (15% with incentives compared to 5% without). They care about how many benefit and reported a 21% incentives-abetted tobacco quit rate compared to the 12% rate without incentives. And they care about who signs up. Their results from this and all of their studies delve deeply into demographic differences between those who are more or less influenced by incentives.

This commentary in defense of incentives derives from my perception that Dean is not alone in blithely abandoning a baby that deserves better. Let’s be clear though. Those bathwater-smelling incentive schemes are NOT wellness programs. Any right minded well-being practitioner knows incentives are but a tactic within a well designed, culturally supported, and evidence-based curriculum of offerings and initiatives. Dean’s common sense model doesn’t include a health coach because their “primary objective is to meet the set number of contacts in a month.” Having coached alongside many talented coaches and profiled many of their successes on these pages, I can assure you that their primary objective is to support others in health improvement. A place where clever and intrinsically responsive incentives are helping connect people to skillful and empathetic coaches is a place that will surely care how many people sign up.

Do financial incentives work? Like most emerging science, some studies say yes and others no. This baby will crawl before she walks. Still, tobacco taxes have an established legacy as one of the most powerful influencers of the public’s health; fat and sugar taxes are next. Tom Farley’s new book Saving Gotham5 chronicles the work of Mayor Bloomberg’s public health department and their monumental policy wins against powerful purveyors of sugar, salt, and tobacco. Farley draws a sharp, direct line from behavioral economics to 8 million lives saved. With that as an outcome, pan incentives with whatever names you want, but please be careful when you’re throwing out the bathwater.

Paul E. Terry, PhD is President and CEO of HERO (Health Enhancement Research Organization).

1Plus3 Network, accessed February 11, 2016, www.plus3network.com.
2Stickk.com, accessed February 11, 2016, www.stickk.com.
3National Center for Biotechnology Information (NCBI), accessed February 11, 2016, www.ncbi.nlm.nih.gov/pubmed/?term=Volpp+KG.
4Volpp, Kevin G. et al. A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation, New England Journal of Medicine 360, no. 7 (2009): 699-709.
5Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives, Amazon.com, accessed February 11, 2016, www.amazon.com/Saving-Gotham-Billionaire-Activist-Doctors/dp/0393071243.


# Edward Framer 2016-03-30 00:08
Thank you, Paul; a needed missive. Early wellness use of incentives has tended to be heavy handed. No wonder Dean didn't like them. I hope that as time goes by we, as a field, will learn to use incentives with a softer, more thoughtful touch. When I hear about simplistic implementations , especially those with a heavy penalty emphasis (should we really call those incentive-based ) I know that the designers do not understand incentive use. It is easier to steer a car once it is rolling; and well designed incentive programs help with new behavior and active participation. They take a lot of thought and a bone-deep knowledge of human motivation. Decades ago, Murray Sidman wrote his classic book, Coercion and Its Fallout. The fallout is ugly. Incentive uses cannot afford heavy handed coercion; and even their positive use is best when time limited. Eventually we have to transfer to "natural" rewards, such as good feelings and thoughts, to inexpensively sustain incentive driven change.
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# Dean Witherspoon 2016-03-30 15:38
"...bone-deep knowledge of human motivation." I wish I had said that, but glad you did, Ed. Thanks for commenting.
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