In an essay on medical ethics, Harald Schmidt explores the question: is it right for employers and health plans to offer incentives to employees/members to pursue health care that is not informed by evidence? He uses as his example several large insurers paying young (younger than 50, even younger than 40 years), low-risk women to obtain mammograms. The evidence has been recently reviewed: just last week, the United States Preventive Services Task Force again used this evidence to recommend that women at average risk for breast cancer begin getting regular mammograms at age 50, and then every other year until age 74. The American Cancer Society recommends yearly mammography from ages 45 to 54, then screenings every other year afterward.
Mammograms are not without risk. Many women getting mammograms will receive entirely unnecessary treatment and anxiety because of false positive readings. He recommends that if incentives be used, that they incentivize use of mammogram decision aids, rather than incentivizing getting the mammogram itself. He cites a randomized trial of decision aids for women that showed that more informed women are less inclined to have mammograms.
Incentives are not limited to mammography. An analysis by the RAND Corporation found that half of all organizations with 50 or more employees have programs that incentivize health screenings or other “wellness” activities. Workers increasingly are being told by their employers to undergo health screenings and enroll in wellness programs as a way to curb insurance costs. The programs often involves stiff financial penalties — often in the form of higher premiums — for not participating in activities such as cholesterol screening, weight loss programs or diabetes management.
In contrast to mammography in young women, some of these “wellness” activities are recommended by the US Preventive Services Task Force. Despite this, a New York Times Upshot review of the evidence related to workplace “wellness” programs have shown that they often do not work. Although some observational studies suggest improvements in health, more rigorous studies tend to find that wellness programs don’t save money and, with few exceptions, do not appreciably improve health. This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.
I recently overheard employees at a local company saying that they figured out how to game the company’s wellness program by creating unhealthy online baseline profiles, pretending to be overweight chain-smokers, and then demonstrating the incremental improvements rewarded by the wellness program’s quarterly surveys. The program did not reward participants who maintained non-smoking, non-overweight status–or those who were honest about being trim non-smokers–only those who made real or fictitious progress towards this status.
Schmidt concludes his essay by recommending that we incentivize decision-making, rather than specific decisions. Evidence-based decision aids can help patients optimize the quality of their decision, personalizing the right decision to the right patient based on medical and value-driven considerations. He concludes:
Incentives are not appropriate in all contexts. When it comes to breast screening, the right way forward is for all payers to offer incentives for using optimized evidence-based decision aids—irrespective of the ultimate decision in favor or against screening. Doing so promotes autonomy by minimizing regret that may result both from having and not having undergone screening. Incentivized active choice can furthermore assist with reducing disparities between income and educational groups.
Policy makers implementing the Institute of Medicine’s recommendation by making mammography completion rates a priority measure should complement this initiative with measuring the informedness of decision making. A focus on completion rates alone is ethically misguided given that the balancing of potential benefits and harms is highly preference sensitive.