We seem to have no problem penalizing patients for being unhealthy--see our episode on wellness programs, for instance. But we rarely consider paying patients to be healthier. Why is that?

The New England Journal of Medicine has a study to change your mind. this is Healthcare Triage News.

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The paper is entitled, "Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation" and it appeared in the May 28th issue. So here's the deal: researchers randomly assigned employees, along with their relatives and friends, to one of four programs to help them quit smoking, or they were assigned to usual care.

The randomization was stratified over two variables, whether they had full healthcare benefits through the employer and whether their annual household income was at least $60,000. This was to balance recruitment in those areas.

Two of the programs involved an individual incentive. The first was a straight payment system, participants getting $200 at 14 days, 30 days, and 6 months, and a potential $200 bonus at the end of their enrollment if they were still not smoking. So they could get $800 total, potentially. They were checked by laboratory tests to see if they were smoke-free.

The second individual assessment was the same, but involved requiring the participants to pony up a refundable $150 at the start of the trial. They'd get that back if they didn't smoke, along with the incentive payments.

The other two groups were collective. The first was collaborative. Participants were enrolled in groups of six, and at each time point, they all received $100 for each member that was still smoke-free. In this way, they could earn up to $600 per check point, with the $200 bonus still available. Thus, there was $2000 total potentially available, depending upon how many in the group stuck with it. This was supposed to see if getting people incentivized to work together might help them to quit.

The last group was competitive, and also involved deposits. Everyone had to pony up 150 bucks of their own money to start, and they'd get that back along with other money along the way. People were paid more if others failed. They could receive up to $1200 at each time period, with the $200 bonus at end, for a potential of $3800 total if everyone else didn't make it. Again, they got more money if fewer people quit. They were kept anonymous, though, so people couldn't sabotage each other.

They got more than a thousand people to participate in this. Overall, people liked the rewards program much more than they liked the deposit programs. About 90% agreed to participate in the rewards program once they heard about it, versus only about 14% in the deposit programs once they heard about 'em.

In other words, they didn't like the idea of risking their own money, which is understandable. But what we really care about are the quit rates. In an intention-to-treat analysis, the quit rates were significantly higher with all of the incentive programs than with usual care, which had a quit rate of 6%.

At 6 months, the individual deposit program had a quit rate of 9.4% and the competitive deposit program was 11.1%. The individual rewards program had a quit rate of 15.4%, and the collaborative rewards program had a quit rate of 16%.

The sad news is that all of these pretty much halved at 12 months, but still--the programs were generally better than usual care. But still, more quitting is better. So how much did it cost for each 6-month quit?

It was $122 for usual care, $1058 in individual rewards, $1193 in collaborative rewards, $542 in individual deposits, and $858 in competitive deposits.

Is that worth it? Might be! We pay a lot more for things that do us a lot less good, than quitting smoking would.

Healthcare Triage is supported in part by viewers like you through Patreon, a service that allows you to support the show through a monthly donation. We'd like to thank all our Patreon supporters in general, and thank our honorary research associate Cameron Alexander specifically. Thanks, Cameron!

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