BSSR lecture Series: Behavioral Economics, Classical Economics, Public Policy, Politics, and Health


Uploaded by NIHOD on 07.06.2012

Transcript:
GOOD MORNING.
MY NAME IS DEBRA OLSTER FROM THE
OFFICE OF BEHAVIORAL AND SOCIAL
SCIENCES RESEARCH.
WELCOME TO OUR FIRST TALK OF THE
SEASON AS IT WERE.
I'M REALLY PLEASED TO BE ABLE TO
INTRODUCE OUR SPEAKER TODAY,
DR. GEORGE LOWENSTEIN, THE
HERBERT A. SIMON PROFESSOR OF
ECONOMICS AND PSYCHOLOGY AT CASH
GIVE MELON UNIVERSITY.
GOT HIS Ph.D. FROM YALE AND
HELD ACADEMIC POSITIONS AT MANY
PLACES, UNIVERSITY OF CHICAGO,
CARNEGIE MELON.
THE INSTITUTE FOR ADVANCED STUDY
AT PRINCETON, THE RUSSELL SAGE
FOUNDATION AND INSTITUTE FOR
ADVANCED STUDY IN BERLIN.
HE HAD MANY DISTINGUISHED HONORS
BUT I DON'T WANT THE TAKE AWAY
FROM HIS TIME BECAUSE WE REALLY
WANT TO HEAR WHAT HE HAS TO SAY,
NOT WHAT I HAVE TO SAY.
SO WITH THAT, I WILL TURN OVER
THE MICROPHONE.
THE TITLE OF HIS TALK IS
BEHAVIORAL ECONOMICS, CLASSICAL
ECONOMIC, PUBLIC POLICY,
POLITICS AND HEALTH.
HELP ME WELCOME DR. LOWENSTEIN.
[APPLAUSE]
>> DR. OLSTER INVITED ME A LONG
TIME AGO AND ASKED ME TO COME UP
WITH A TITLE SO I TRIED TO COME
UP WITH A TITLE THAT WAS
SUFFICIENTLY EXPANSIVE SO I
COULD GIVE ANY TALK THAT I
WANTED TO GIVE WHEN THE TIME
CAME.
BUT HOPEFULLY THE TALK ITSELF IS
A LOT SHORTER THAN THE TITLE
BECAUSE I REALLY AM HOPING THAT
WE'LL HAVE TIME FOR DISCUSSION.
THIS IS RESEARCH I'M TALKING
ABOUT RESEARCH WITH KEVIN VOLP
AND A NUMBER OF OTHER
COLLEAGUES, WHO I'LL ACKNOWLEDGE
AS WE GO ALONG AT CARNEGIE
MELON, PENN, HARVARD OTHER
PLACES.
A BETTER TITLE MIGHT BE
REDESIGNING EMPLOYEE HEALTH
INCENTIVES, LESSONS FOR
BEHAVIORAL ECONOMICS, MY TALK IS
LOOSELY BASED ON A FORTHCOMING
PAPER THAT WE HAVE.
SO THIS IS NOT GOING TO BE NEW
TO ANYBODY BUT HEALTHCARE COSTS
IN THIS COUNTRY ARE OUT OF
CONTROL.
MUCH HIGHER THAN IN ANY OTHER
COUNTRY IN THE WORLD PER CAPITA.
IF YOU DO A REGRESSION WHERE YOU
LOOK AT THE WAY YOU LOOK AT
HEALTH EXPENDITURES AS A
FUNCTION OF INCOME, YOU SEE
THERE'S A REALLY NICE LINE,
THESE ARE DIFFERENT COUNTRIES
WITH ONE OUTLIER.
THAT IS THE UNITED STATES HIS
OUTLIER ISN'T IN THE RIGHT
PLACE, IT WOULD HAVE TO BE OFF
THE GRAPH, THERE'S NO ROOM ON
THE GRAPH FOR THE UNITED STATES.
THERE'S A LOT OF POTENTIAL,
POTENTIALLY EFFECTIVE REMEDY FOR
DEALING WITH THE PROBLEM OF OUT
OF CONTROL HEALTHCARE COSTS.
WE COULD FOR EXAMPLE, CEASE
REIMBURSEMENT OF HIGH COST TESTS
AND PROCEDURES THAT ARE
QUESTIONABLE VALUE AND THAT
BRITAIN HAS OF COURSE BEEN A
LEADER IN THIS AREA WITH THEIR
NICE PANEL.
WE CAN ELIMINATE EASILY
AVOIDABLE CONFLICTS OF INTEREST
WHICH IS ANOTHER RESEARCH OF
INTEREST OF MINE.
WE COULD THE COMPENSATION OF
DOCTORS MINIMIZING FEE FOR
SERVICE ARRANGEMENTS.
PROBABLY ALL OF THESE WOULD BE
POTENTIALLY IF THEY WERE
IMPLEMENTED THE RIGHT WAY COULD
BE EFFECTIVE REMEDIES FOR THE
OUT OF CONTROL HEALTHCARE COSTS.
NONE OF THESE ARE PART OF THE
HEALTHCARE REFORMO:# BILL,
UNFORTUNATELY.
ONE OTHER POSSIBLE AVENUE OF
COST CUTTING OTHER THAN THE ONES
I MENTIONED, TO CHANGE
INDIVIDUAL'S HEALTH BEHAVIORS.
IF WE COULD ONLY MAKE PEOPLE
HEALTHIER WE WON'T HAVE TO GIVE
THEM HEALTHCARE.
AND OF COURSE, THERE'S SOME
LOGIC TO THAT, IT'S BETTER TO
PREVENT A CASE OF LUNG CANCER
THAN TO TREAT IT.
THERE IS LOGIC TO TRYING TO
CHANGE HEALTHCARE BEHAVIORS.
HEALTHCARE BEHAVIORS ARE
UNDENIABLY DISASTROUS.
WE HAVE OBESITY EPIDEMIC IN THIS
COUNTRY.
THE OBESITY RATE WENT FROM 13%
TO 31% FROM 1960 TO 2000, OVER
HALF OF THE POPULATION IS
OVERWEIGHT.
IT'S BEEN ESTIMATED LIFESTYLE
DISEASES, TOBACCO, ALCOHOL USE
AND OBESITY ACCOUNT FOR A THIRD
OF PREMATURE DEATHS IN THIS
COUNTRY.
WE DO HAVE A VARIETY OF
POTENTIALLY BENEFICIAL
TREATMENTS AND MEDICATIONS TO
CONTROL THESE LIFESTYLE DISEASES
AND ALSO NON--- OTHER TYPES OF
DISEASES.
HOW FAR, THE EFFECTIVENESS OF
THESE MEDICATIONS AND TREATMENTS
IS STYMIED BY POOR ADHERENCE.
HERE IS ONE STUDY BY JACK AVITIS
ET AL WHICH LOOKED AT THE RATE
OF STATIN ADHERENCE OVER TIME
FOR A DIFFERENT POPULATION.
AND THE BOTTOM -- THE BOTTOM
LINE IS PEOPLE WITH ACUTE
CORONARY SYNDROME.
YOU CAN SEE MOST PEOPLE ARE --
THEIR ADHERENCE IS DROPPING TO
-- THE AVERAGE PERSON, SORRY,
THAT WOULD BE THE TOP LINE, NOT
THE BOTTOM LINE.
FOR AVERAGE PERSON ADHERENCE IS
DROPPING TO 50% AFTER LESS THAN
A YEAR AND BUT EVEN FOR PEOPLE
WITH ACUTE CORONARY SYNDROME,
AFTER ABOUT TWO YEARS, ONLY HALF
OF THEM ARE TAKING THEIR
STATINS.
YOU THINK THAT THEY WOULD BE
HIGHLY MOTIVATED TO TAKE
MEDICATIONS TO AVOID ANOTHER
HEART ATTACK BUT THEY'RE NOT,
STRANGELY ENOUGH.
POOR MEDICATION ADHERENCE
ASSOCIATED WITH HIGHER RATES
DISEASE, INCREASED HEALTHCARE
COSTS.
IT'S ESTIMATED ONE ESTIMATE IS
$100 BILLION PER YEAR, THE COST
OF POOR MEDICATION ADHERENCE.
AND IT'S GENERALLY THE CASE THAT
EFFICACIOUS MEDICATIONS DON'T
HAVE AN IMPACT IF PEOPLE DON'T
TAKE THEM, OBVIOUSLY.
THE HEALTHCARE REFORM BILL
INCLUDES SEVERAL PROVISIONS
AIMED AT CHANGING M&A HEALTH
BEHAVIORS, ONE IS TALLRY POSTING
AT -- CALORIE POSTING AT
MANDATES.
CALORIE POSTING AT CHAIN
RESTAURANTS NATIONALLY.
I HAVE ACTUALLY DONE A LOT OF
RESEARCH ON THIS AND MANY OTHER
PEOPLE HAVE AND WITH THE
EXCEPTION OF ONE STUDY THAT
LOOKED AT PEOPLE AT STARBUCKS
WHICH IS NOT EXACTLY THE TARGET
OF THE LEGISLATION, WITH THE
EXCEPTION OF THAT ONE STUDY ALL
STUDIES REACH SIMILAR
CONCLUSIONS, THATCAL CALORIE
POSTING DOESN'T HAVE AN IMPACT
ON EATING BEHAVIOR.
ANOTHER APPROACH OF THE
HEALTHCARE REFORM BILL IS
VALUE-BASED INSURANCE DESIGN
SECTION 226, 13 OF THE
AFFORDABLE CARE ACT MANDATES
RECOMMENDED SERVICES BE COVERED
WITHOUT COST SHARING.
ONE AGAIN, THIS SOUNDS LIKE A
GOOD IDEA, IT IS THE CASE WHEN
YOU RAISE THE CO-PAYS ON
SERVICES THAT FEWER PEOPLE GET
THEM.
HOWEVER ALL THE RESEARCH THAT I
HAVE SEEN AND QUITE A BIT OF
RESEARCH, HAS NOT FOUND
GENERALLY WHEN YOU LOWER CO-PAYS
ON MEDICATION THAT MORE PEOPLE
TEND TO TAKE THEM.
SO VBIT AS CALLED DID NOT SEEM
TO BE A VERY EFFECTIVE WAY OF
GETTING PEOPLE TO TAKE THEIR
MEDICATION.
THAT ACTUALLY RELATES TO THE
GENERAL THEME OF MY TALK.
FINALLY THE HEALTHCARE REFORM
BILL INTRODUCES PROVISIONS TO
CONDITION HEALTH PREEMS ON --
PREMIUMS ON HEALTH BEHAVIORS.
THE SO-CALLED SAFE WAY AMENDMENT
ALLOWS UP TO 50% PREMIUM
ADJUSTMENTS BASED ON
OUTCOME-BASED ASSESSMENTS,
SMOKING, BMI, BLOOD PRESSURE,
CHOLESTEROL.
THIS IS CALLED THE SAFEWAY
AMENDMENT BECAUSE IT'S BASED ON
SAFEWAY'S CLAIMS OF FLAT COST
THE PAST FIVE YEARS FROM TIME
PREMIUMS TO BIOMETRIC MEASURES.
HOWEVER, THERE'S BEEN A LOT OF
CHALLENGES TO SAVEWAY'S CLAIMS
AS THE WASHINGTON POST ARTICLE
HEADLINE IS MISLEADING CLAIMS
ABOUT SAFEWAY WELLNESS INCENTIVE
SHAPE HEALTHCARE BILL.
IF YOU LOOK CAREFULLY, THEIR
FLAT COSTS PRECEDED THE
INTERVENTION THAT THEY
INTRODUCED.
SO IT DOESN'T MAKE ANY SENSE TO
CLAIM THEIR INTERVENTIONS CAUSED
THE FLAT COST.
BEYOND THIS EVIDENCE FROM SO
CALLED EVIDENCE FROM SAFEWAY,
THERE'S LITTLE EVIDENCE THIS
APPROACH IS EFFECTIVE, THIS
APPROACH BEING THE APPROACH OF
CONDITIONING, PREMIUMS, ON THESE
DIFFERENT HEALTH MEASURE,
BEHAVIOR AND OTHER MEASURES.
THE MAIN PURPOSE OF HEALTH
INSURANCE IS TO REDISTRIBUTE
BURDENS OF ILLNESS BETWEEN
HEALTHY PEOPLE AND SICK PEOPLE.
KIND OF TO SHARE THE COST OF
POOR HEALTH.
THE SAFEWAY AMENDMENT WILL
UNDERMINE THIS PURPOSE AND WILL
INCREASE PREMIUMS FOR LOW INCOME
FAMILIES AN MINORITIES WHO HAVE
WORSE HEALTH BEHAVIORS AND IT'S
GOING TO LOWER PREMIUMS FOR
HEALTHY PEOPLE.
THAT IS REGRESSIVE.
THE STATED PURPOSE OF THE
SAMEWAY AMENDMENT IS TO PROMOTE
HEALTHY BEHAVIORS AND REDUCE
COST.
THE WORST POSSIBLE OUTCOME WILL
BE IF THE SAFEWAY AMENDMENT
INTRODUCES GREATER REGRESSIVITY,
CAUSES POOR UNHEALTHY PEOPLE,
POOR PEOPLE ARE MORE LIKELY TO
SMOKE, HAVE HIGHER BMIs, SO
ON, CAUSES EXACT PEOPLE WHO
CAN'T AFFORD THE PREMIUMS TO
RAISE THEIR PREMIUMS.
AT THE SAME TIME IT HAS LITTLE
IMPACT ON BEHAVIOR.
THAT'S THE WORST POSSIBLE
OUTCOME.
SO WHAT CAN BEHAVIORAL ECONOMICS
CONTRIBUTE TO THIS?
THE TRAIN HAS LEFT THE STATION
ON THE SAFEWAY AMENDMENT AS PART
OF HEALTHCARE REFORM.
SO WE CAN'T DO ANYTHING ABOUT
THAT.
BUT A MAJOR IMPLICATION OF
BEHAVIORAL ECONOMICS IS THAT A
DOLLAR DOES NOT EQUAL A DOLLAR
DOES NOT EQUAL A DOLLAR.
WHAT I MEAN BY THAT IS YOU CAN
-- THERE ARE WAYS OF DELIVERING
INCENTIVES TO PEOPLE WHERE YOU
MIGHT AS WELL BURN THE MONEY.
IT'S GOING TO HAVE NO IMPACT ON
PEOPLE.
THERE ARE OTHER WAYS OF TAKING
EXACTLY THE SAME INCENTIVES AND
MAKING THEM MUCH MORE EFFECTIVE.
HOW PREMIUM CONDITIONING IS
IMPLEMENTED IS GOING TO
DETERMINE WHETHER OR NOT IT
CHANGES BEHAVIOR.
THAT IS WHETHER OR NOT WE IN
ADDITION TO THE REGRESSIVITY OF
THE SAFEWAY AMENDMENT WE GET
SOME BENEFITS FROM IT.
LET ME CHANGE GEARS FOR A MOMENT
TO LEAVE THE DOMAIN OF
HEALTHCARE BEHAVIOR AND I WILL
STRAIT MY POINT WITH TWO
DIFFERENT PROGRAMS DESIGNED TO
STIMULATE SAVINGS BEHAVIOR AMONG
LOW INCOME PEOPLE.
THESE ARE PROGRAMS NOT IN THE
DOMAIN OF HEALTH BUT ILLUSTRATE
THE THEME THAT I'M TRYING TO
CONVEY.
SO THE PROBLEM IS, WE HAVE ALSO
TAX PROTECTED SAVINGS IN THIS
COUNTRY LIKE IRAs, 401(K)s,
SO ON.
BUT IN THIS ONLY GIVE YOU
BENEFITS.
THEY GIVE YOU BENEFITS TO THE
DEGREE YOU'RE IN A HIGH TAX
BRACKET BECAUSE THEY GIVE YOU
TAX DEDUCTIONS, THAT'S ONLY
HELPFUL TO YOU IF YOU'RE IN A
HIGH INCOME TAX BRACKET.
SO POOR PEOPLE DON'T GET THE
SAME BENEFITS FOR SAVING AS RICH
PEOPLE SO THERE'S BEEN PROGRAMS
TO TRY TO GIVE PEOPLE THE SAME
BENEFITS THAT RICH PEOPLE ENJOY
AND TWO DIFFERENT PROGRAMS WERE
TESTED BY RESEARCHERS
COLLABORATING WITH H&R BLOCK.
THE FIRST ONE IS CALLED THE
SAVER'S CREDIT EPIACTED IN 2001.
IN THIS PROGRAM THERE WAS A
FEDERAL INCOME TAX REDUCTION OF
UP TO 50% OF FUNDS CONTRIBUTED
TO AN IRA.
SO IT'S A -- IF A LOW INCOME
INDIVIDUAL CONTRIBUTED $100 TO
THE IRA, THE TAXES WOULD BE CUT
BY $50.
IT'S EFFECTIVELY 100% MATCH.
YOU PUT IN $50 EFFECTIVELY YOU
GET $100.
100% MATCH ON YOUR SAVINGS.
SOLUTION 2, WAS A SAVINGS MATCH,
THIS WAS TESTED A FEW YEARS
LATER.
AND IN THIS SOLUTION, CLIENTS
PREPARING TAX RETURNS AT H&R
BLOCK OFFICES WERE ASSIGNED TO
ONE OF THREE MATCH RATES FOR IRA
CONTRIBUTION.
A CONTROL GROUP THAT GOT NO
MATCH A 20% MATCH GROUP SO EVERY
$100 THEY PUT IN H&R BLOCK Z IT
APPEARED TO THEM ANYWAY, PUT IN
THE EXTRA $20.
AND THERE WAS ALSO A 50% MATCH
WHERE THERE WAS 100-DOLLAR
SAVINGS, AN EXTRA $50.
SO YOU CAN SEE SOLUTION 2 IS
CONSIDERABLY LESS GENEROUS THAN
SOLUTION 1.
LET'S TAKE A LOOK AT WHAT THE
RESULTS THAT SAVERS CREDIT, THE
TAKEUP RATE WAS 3% AND AMONG
THOSE 3%, THE AVERAGE
CONTRIBUTION TO THE IRA
WAS $150.
IF YOU LOOK AT THE MATCH
EXPERIENCE THE CONTROL, THE 3%
TAKE UP RATE, THEY DIDN'T GIVE
BUT 3% CONTRIBUTED TO THE IRA
THERE AND THEY CONTRIBUTED AN
AVERAGE OF 765.
THESE ARE TWO DIFFERENT
POPULATION GROUP, TWO DIFFERENT
YEARS SO YOU CAN'T DO STRICTLY
COMPARE THE TWO BUT IT DOESN'T
LOOK LIKE THE SAVER'S CREDIT HAD
MUCH IMPACT.
HOWEVER, IF YOU LOOK AT THE 20%
MATCH, THERE'S 8% TAKE UP RATE,
$1,100 CONDITIONAL AVERAGE
CONTRIBUTION AND WITH THE 50%
MATCH IT WAS A 14% TAKE UP RATE.
THE POINT IS THESE TWO PROGRAMS
THE MORE GENEROUS PROGRAM HAD
SEEMINGLY NO IMPACT ON BEHAVIOR,
THE LESS GENEROUS PROGRAM HAD
QUIT A BIG IMPACT ON BEHAVIOR.
THE POINT IS THAT REALLY MATTERS
HOW YOU IMPLEMENT INCENTIVES.
WHY THE DIFFERENCE IN THE
OPPOSITE DIRECTION FROM THE
OBJECTIVE INCENTIVES PROBABLY
HAS SOMETHING TO DO, CONJECTURE
T SAVER'S CREDIT THE BENEFIT WAS
INTEGRATED WITH THE INCOME TAX
SO IT WAS NOT VERY SALIENT TO
THEM.
SECOND, THE REDUCTION NOT VERY
LARGE COMPARED TO THE AMOUNT OF
TAX THEY WERE PAYING SO THE
REDUCTION WAS AMORPHOUS TO THEM.
THE MATCH IN CONTRAST WAS
SEPARATED AND MORE AS A RESULT
MORE SALIENT.
AND WITH A MATCH IT FEELS LIKE
YOU'RE GETTING A GIFT YOU'RE
GOING FOREGO IF YOU DON'T PUT
THE MONEY ASIDE.
LIKE SOMEONE IS READY TO GIVE
YOU $20, AND YOU'RE GOING TO
GIVE UP THE $20 IF YOU DON'T PUT
IN YOUR OWN $100.
SO THE SECOND ONE IS
PSYCHOLOGICALLY VERY DIFFERENT
THOUGH FROM AN ECONOMIC
PERSPECTIVE IT'S LESS GENEROUS.
MOST HEALTH PROGRAMS IGNORE THE
MOST BASIC LESSON OF ECONOMICS.
HERE IS A PROGRAM THAT OFFERED
BY A INSURANCE COMPANY, A
FITNESS PROGRAM GET THEM TO
EXERCISE, THEY GET UP TO $150
BACK FOR JOINING AND USING THE
GYM.
PICTURE OF ATTRACTIVE PEOPLE.
THAT PART IS PROBABLY GOOD.
THAT PROBABLY DOES HELP PEOPLE
TO EXERCISE.
AMONG OTHER THINGS, REGULAR
PHYSICAL ACTIVITY CAN HELP YOU
REDUCE CHOLESTEROL, TELLS YOU
WHY YOU SHOULD DO IT.
COMPLETE 120 WORK OUTS IN 365
DAYS AND YOU'RE ELIGIBLE FOR A
REIMBURSEMENT OF UP TO $150.
WELL, IF YOU WANT TO BURN $150,
YOU COULDN'T COME UP WITH A
BETTER WAY OF DOING IT.
THIS HAS DESIGN FLAW, REWARDS
ARE ONCE A YEAR.
THAT'S A SINGLE HIGH THRESHOLD,
HOW MANY GO TO THE GYM 120 TIME?
PROBABLY ONLY PEOPLE WHO ARE
ALREADY GOING TO THE GYM 120
TIMES.
SO THIS PROGRAM IS GOING TO
SPEND $150 WHO ARE GOING TO
EXERCISE ANYWAY.
ISN'T GOING TO GET ANYBODY WHO
WASN'T EXERCISING TO EXERCISE F.
YOU LOOK AT TYPICAL HEALTHCARE
PLAN, THIS IS JUST LIKE THE YOU
HAVE TO MAKE A DECISION BETWEEN
TWO PLANS, IF YOU LOOK AT THE
TYPICAL HEALTHCARE PLAN, I WON'T
GO THROUGH THE DETAILS BUT ALL
OF YOU KNOW THE TYPICAL
HEALTHCARE PLAN IS ABSOLUTELY
BEWILLERRING.
OBVIOUSLY A LOT OF THOUGHT WENT
TO DESIGNING THAT PLAN.
THERE'S A LOT OF DETAIL.
THE DESIGNERS OF THE PLAN WANTED
TO INCENTIVIZE THE SUBSCRIBERS
TO BEHAVE IN REALLY SPECIFIC
WAYS.
BUT AFTER WAY MORE THAN AN HOUR
OF SCRUTINY, BY ONE PERSON WITH
A Ph.D. IN ECONOMICS,
OBVIOUSLY MYSELF, I COULDN'T
FIGURE OUT WHAT THESE PLANS ARE
ALL ABOUT.
IN FACT, I COULDN'T FIGURE OUT
WHAT THE FUNDAMENTAL DIFFERENCE,
BETWEEN THE TWO PLANS WAS OR
WHICH PLAN I WOULD PERSONALLY
CHOOSE.
IF YOU CAN'T UNDERSTAND HOW THE
PLANS WORK, HOW CAN THEY
POSSIBLY INCENTIVIZE YOU TO
BEHAVE IN ANYWAY?
SO OUR APPROACH KEVIN AND RYAN
AND OUR COLLABORATORS, OUR
GENERAL APPROACH IS TO USE
DECISION ERRORS TO HELP PEOPLE.
SO BEHAVIORAL ECONOMICS IS %w VERY
CONCERNED WITH A COMMON DECISION
ERRORS THAT PEOPLE MAKE IN DAY
TO DAY LIFE AND THE APPROACH
THAT WE HAVE BEEN TAKING IS TO
TRY TO USE THE SAME ERRORS THAT
USUALLY HURT PEOPLE TO INSTEAD
HELP THEM.
FOR EXAMPLE, PEOPLE TEND TO BE
VERY SHORT CITED.
THEY'RE VERY ORIENTED TOWARDS
IMMEDIATE COST AND BENEFITS.
THAT'S USUALLY A BAD THING.
THAT'S PART OF THE REASON WHY WE
DON'T SAVE MONEY, IT'S PART OF
THE REASON WE GAIN WEIGH BECAUSE
THE IMMEDIATE FOOD IS VERY
ATTRACTIVE TO US.
IT'S POSSIBLE TO PLAN BIASES AND
INCENTIVE PROGRAMS FOR MAKING
REWARDS FOR BENEFICIAL BEHAVIOR
FREAK AND IMMEDIATE.
STEVE HIGGINS AND HIS COLLEAGUES
WHO DO RESEARCH WITH DRUG
ADDICT, THEY DO PROGRAMS WITH
DRUG ADDICTS HAVE HAD REMARKABLE
SUCCESS.
YOU TAKE AN ADDICT, ADDICT IS
LIVING ON THE STREET, LOST
FAMILY, UNEMPLOYED SO ON, THEY
HAVE EVERY MOTIVE TO KICK THEIR
HABIT, THEY DON'T KICK THEIR
HABIT.
YOU GIVE THEM SMALL COUPONS GOOD
FOR SMALL REWARDS LIKE AT STORES
AND ALL OF A SUDDEN IT HAS A
HUGE IMPACT ON BEHAVIOR.
THE MUCH LARGER IMPACT
MOTIVATION TO KICK THE HABIT AND
GET YOUR LIFE TOGETHER DOESN'T
SEEM TO WORK.
FRAMING AND SEGREGATING REWARDS
HAVE TALKED ABOUT THAT WITH THE
TAIL OF THE TWO TAX PROTECTED
SAVINGS PROGRAMS.
BUT $100 REWARD IS MUCH MORE
LIKELY TO BE EFFECTIVE THAN $100
DISCOUNT ON A HEALTH PREMIUM FOR
MANY REASONS, FOR ONE THE $100
REWARD IS SEPARATED AND TWO, NOT
BURIED IN A MUCH LARGER AMOUNT.
PEOPLE TEND TO OVERWEIGH SMALL
PROBABILITIES SO IN A LOT OF
RESEARCH AS YOU SEE WE OFTEN
GIVE PEOPLE LOTTERY REWARDS.
PEOPLE LOVE LOTTERIES IN PART
BECAUSE THEY EXAGGERATE THE
LIKELIHOOD OF WINNING SO IF
PEOPLE LOVE LOTTERIES LET'S GIVE
THEM LOTTERY REWARDS.
I WOAP GO THROUGH THE PSYCHOLOGY
IN GREAT DETAIL BUT IN
HEALTHCARE VERY MUCH LIKE IN
SAVINGS FOR LOW INCOME FAMILIES
AND HEALTHCARE HOW YOU IMPLEMENT
A PROGRAM MAKES A BIG
DIFFERENCE.
THIS IS A STUDY WITH EMILY
HAZILY A FORMER GRADUATE
STUDENT, KEVIN AND TOM AND IN IT
A HEALTHCARE COMPANY HEAD
QUARTERED IN PITTSBURG TOLD US
THEY WERE HAVING TROUBLE GETTING
THEIR EMPLOYEES TO COMPLETE
HEALTH RISK ASSESSMENTS AND B
ASK FOR OUR HELP.
THEY WERE PLAYING PLOAM
EMPLOYEES TO COMPLETE A HRA AND
WILLING TO GO UP TO $50.
SO WE GAVE EVERYONE $25 CASH
INCENTIVE FOR COMPLETING THE HRA
AND THERE WAS A CONTROL GROUP
THAT GOT NO EXTRA REWARD.
THEN THERE WAS A DIRECT PAYMENT
GROUP WE GAVE THEM ADS 25 GIFT
CERTIFICATE, EVERYONE SHOPS FOR
GROCERIES.
EFFECTIVELY WE DOUBLED THEIR
MONETARY REWARD.
THEN WE INTRODUCED A LOTTERY
CONDITION, WHICH IS ONE OF THESE
BEHAVIORAL ECONOMICS
INTERVENTIONS THAT PLAYS ON
BIASES.
WE DIVIDE EMPLOYEES EACH WEEK
ONE SIDE WAS RANDOMLY SELECTED.
IN THE SELECTED GROUP WHO
COMPLETED AN HRA WON $100.
INDIVIDUALS IN THE GROUP WHO
HADN'T COMPLETED THE HRA KNEW
THAT THE OTHER PEOPLE IN THE
GROUP HAD HAD COMPLETED HRAs
AND RECEIVED $100 AND THEY
MISSED OUT ON $100.
WE INCREASED THE PRIZE TO $125
IF80% OF THE WORK GROUP
COMPLETED THE HRA.
YOU CAN SEE WE'RE PLAYING ON
GROUP PRESSURE, PLAYING ON
REGRET.
AND PEOPLE'S LOVE OF LOTTERIES,
SO ON.
AN IMPORTANT FEATURE IS THE
LOTTERY INTERVENTION, THE
EXPECTED VALUE WAS $25.
SO WE CAN GIVE PEOPLE $25 OR WE
CAN GET PEOPLE $25 IN A
DIFFERENT WAY.
HERE ARE THE RESULTS.
THE CONTROL CONDITION GOT $25,
THIS -- THE CONDITION WHERE THEY
GOT $25 AND THE $25 GROCERY
CERTIFICATE IF THEY COMPLETED
THE HRA, AND THE LOTTERY
CONDITION WAS MUCH HIGHERCH THIS
IS A VERY CONSERVATIVE ESTIMATE
OF THE IMPACTHQ OF LOTTERY
CONDITION.
A BUNCH OF PEOPLE COULDN'T SIGN
UP FOR THE LOTTERY FOR COMPLEX
REASONS, AND THIS IS BASED ON
INTENTION TO TREAT.
AND ANOTHER FEATURE OF THIS IS
WE LOOKED AT INCOME, WE LOOKED
AT IMPACT OF THESE INTERVENTIONS
AS A FUNCTION OF INCOME, WE DID
A MEDIAN SPLIT ON THE POPULATION
AND LOOKED AT LOW INCOME PEOPLE
WHO TENDED TO BE LIKE SUPPORT
STAFF.
AND HIGHER INCOME PEOPLE.
IF YOU LOOK AT THE IMPACT AMONG
HIGH INCOME PEOPLE, THE LOTTERY
WAS MORE EFFECTIVE BUT NOT THAT
MUCH MORE EFFECTIVE BUT THE THE
LOTTERY WAS ESPECIALLY EFFECTIVE
AMONG THE LOW INCOME GROUPS.
VERY OFTEN AS WE DISCUSSED
EARLIER, VERY OFTEN LOW INCOME
PEOPLE ARE THE PEOPLE YOU WANT
TO TARGET WITH THESE TYPES OF
INTERVENTIONS BECAUSE THEY TEND
TO HAVE POORER HEALTH AND POORER
HEALTH BEHAVIORS.
THIS IS APPLYING BEHAVIOR TO
ECONOMICS AND WEIGHT LOSS,
EXPLORE DECISION ERRORS TO HELP
PEOPLE MANY THE FIRST STUDY
WEIGHT LOSS, A THREE CONDITION
RANDOMIZED CONTROL TRIAL, THERE
WERE THREE CONDITIONS, CONTROL
CONDITION WHERE THEY WENT TO A
DITITION FOR AN HOUR --
DIETITIAN FOR AN HOUR LONG
SESSION AND A LOTTERY CONTRACT
POSITION.
AT THE START SUBJECTS WERE
OBESE, THEY'RE ALL VETERANS,
ALMOST ALL WERE MALE.
THEY WERE I TOLD YOU THEY ALL
RECEIVE THE ONE HOUR
CONSULTATION.
EVERYONE WAS GIVEN THE GOAL OF
LOSING FOUR POUNDS PER MONTH FOR
FOUR MONTHS.
AT THE END OF EACH MONTH THEY
CAME INTO THE LAB AND THEY WERE
WEIGHED ON OURLY IN THIS CASE
SCALE.
IN THE TWO INCENTIVE CONDITIONS
THEY WERE GIVEN A SCALE TO TAKE
HOME.
IN THE INCENTIVE CONDITIONS THEY
WERE ASKED TO PHONE IN THEIR
DAILY WEIGHT AND WE SENT THEM A
DAILY TEXT MESSAGE.
SO WE'RE TRYING TO GIVE THEM A
LOT OF -- WE'RE TRYING TO GIVE
FREQUENT FEEDBACK CONSISTENT
WITH PRESENT BIAS.
THEY RECEIVE THEIR -- THEY --
THE TEXT MESSAGE IF THEY GET
REWARDS IT TELLS HOW MUCH THEY
RECEIVE.
AT THE END OF THE MONTH WHEN
THEY COME INTO THE CLINIC THEY
GET THE MONEY.
SO IN EFFECT IT'S ALMOST PAYING
THEM TWICE.
WE'RE TELLING THEM HOW MUCH THEY
EARNED SO WE'RE GIVING A
SYMBOLIC REWARD, AT THE END OF
THE MONTH THEY'RE GETTING THE
ACTUAL REWARD SO ALMOST LIKE THE
MONEY IS DOING DOUBLE DUTY.
SO HERE IS SOMEBODY, A VETERAN
WHO STARTS AT 250 POUNDS, THEIR
GOAL IS TO LOSE 16 POUNDS IN 16
WEEKS IN THIS PROGRAM.
IF THEY STAY UNDER THIS LINE,
THEY GET THE REWARDS.
SUPPOSE THEY DON'T STAY UNDER
THE LINE, WHAT TWO WE DO?
ONE THING IS WE COULD HAVE
SHIFTED THE LINE OUT HERE,
PARALLEL LINE LIKE THIS, AND
THEY CAN JUST START AGAIN.
WE DIDN'T WANT TO DO THAT
BECAUSE THAT WOULD PROVIDE THEM
-- THAT WOULD GIVE THEM
INCENTIVE TO PROCRASTINATE, THIS
MONTH I WON'T LOSE WEIGHT AND
NEXT MONTH I'M GOING TO START
THE PROGRAM.
ANOTHER THING WE COULD HAVE DONE
WAS JUST KEPT THIS LINE WHERE IT
IS BUT TAKE SOMEBODY WHO IS HERE
AFTER A MONTH THEY HAVEN'T LOST
ANY WEIGHT AND NOW HAIF TO LOSE
FOUR POUNDS TO GET UNDER THE
GREEN LINE, THEY PROBABLY GIVE
UP AT A CERTAIN POINT.
SO THIS IS KIND OF A COMPROMISE
WHERE THERE'S A FRESH START
TRAJECTORY BUT IT'S STEEPER,
THEY HAVE TO LOSE MORE WEIGHT
EACH -- THEY HAVE TO LOSE MORE
WEIGHT EACH DAY TO STAY UNDER
THE LINE.
THIS IS LIKE TYPICAL DESIGN
CONSIDERATION THAT GOES INTO
THESE TYPES OF PROGRAMS.
SOME IS SCIENCE, A LOT IS JUST
LIKE BRAINSTORMING AND TRYING TO
SOLVE PROBLEMS.
THE LOTTERY INCENTIVE, THE
SUBJECT CHOSE A 2 DIGIT NUMBER.
27.
AND EVERY DAY WE DREW A TWO
DIGIT NUMBER.
IF THE FIRST TWO MATCHED LIKE WE
DREW A 25 OR THE SECOND DIGIT
MATCHED WE DREW A 57, THEY
WON $10.
IF BOTH DIGITS MATCH, THAT'S
ALMOST A 1 IN 5 CHANCE OF
WINNING $10, $2 EXPECTED VALUE.
BOTH DIGITS MATCH THEY WIN $100
AND IT'S A 1 IN 100 CHANCE OF
WINNING $100.
SO THE TOTALED EXPECTED VALUE OF
THE GAMBLE SUICIDE 3 A DAY.
THEY ONLY GET THEIR MONEY, THEY
ONLY GET THEIR WINNINGS IF THEY
CALLED IN THAT DAY AND IF THEY
CALLED IN THEIR WEIGHT AND
REPORTED THEIR WEIGHT BEING
BELOW THE GOAL.
IF THEY CAME AT THE END OF THE
MONTH AND THE WEIGHT WASN'T WHAT
IT WAS REPORTED TO BE, THEY
DIDN'T GET ANY WINNINGS OF
COURSE.
EVERY DAY WE TRANSMITTED A TEXT
MESSAGE TO THE SUBJECT TELLING
THEM WHETHER THEY WON OR WHETHER
THEY WOULD HAVE WON IF THEY HAD
MET THEIR GOAL.
TODAY, YOU WON $10 TODAY BUT TOO
BAD YOU DIDN'T CALL IN YOUR
WEIGHT OR UNFORTUNATELY YOU WERE
ABOVE YOUR TRAJECTORY, WEIGHT
LOSS TRAJECTORY SO YOU DON'T GET
THE $10.
SO WE'RE PLAYING ON REGRET.
SO I HAVE ALREADY SAID THE
LOTTERY INCENTIVE CONDITION
PLAYS ON REGRET AND ALSO PLAYS
ON NON-LINEAR PROBABILITY
WEIGHTING OF PEOPLE'S LAS VEGAS
OF LOTTERIES.
THEY LOVE LOTTERIES SO LET'S
GIVE THEM LOTTERY REWARDS.
SUBJECTS WERE ALLOWED AT THE
BEGINNING OF EACH MONTH THEY
COULD PUT DOWN THEIR OWN MONEY,
FROM A PENNY TO $3 A DAY, TOWARD
WEIGHT LOSS, WE MATCHED EACH
DEPOSIT ONE TO ONE PLUS WE GAVE
THEM ADS 3 DAILY PAYMENT, ALL OF
THESE REWARDS ARE CONTINGENT ON
THEM STAYING BELOW THEIR WEIGHT
LOSS TRAJECTORY.
IF THEY GO ABOVE THE WEIGHT LOSS
TRAJECTORY, THEY LOSE, THEY
DON'T GET OUR MONEY AND THEY
LOSE THEIR OWN MONEY.
THAT'S WHY IT'S CALLED A DEPOSIT
CONTRACT.
THE DEPOSIT CONTRACT CONDITION
PLAYS ON OVEROPTIMISM, PEOPLE
ARE NOTORIOUSLY OVEROPTIMISTIC
ABOUT THEIR ABILITY TO EXERCISE,
ALL TYPES OF SELF-CONTROL
INCLUDING LOSING WEIGHT.
SO PEOPLE SAY I'M GOING TO LOSE
FOUR POUNDS THIS MONTH AND BASE
THOOB THEY'RE READY TO PUT DOWN
A BIG DEPOSIT.
DUE THE A PHENOMENON THAT
ECONOMISTS CALL LOSS AVERSION
PEOPLE HATE LOSING MONEY, THEY
DONE WANT THE LOSE THE MONEY
THEY PUT DOWN, SO IT BECOMES A
SELF-FULFILLING PROPHESY, A
SELF-FULFILLING OVEROPTIMISM.
HERE ARE THE RESULTS.
THIS IS THE TOTAL WEIGHT LOSS,
AGAIN, INTENTIONS TO TREAT BY
CONDITION.
YOU CAN SEE THAT THE LOTTERY AND
THE DEPOSIT CONTRACT WERE BOTH
VERY EFFECTIVE.
WE ASKED THEM A BUNCH OF
QUESTIONS INCLUDING DID THEY
DIET, DID THEY CHANGE EXERCISE.
WE DIDN'T SEE ANY RELATIONSHIP
BETWEEN LOSING WEIGHT AND DIET.
BUT WE SAW A BIG RELATIONSHIP
BETWEEN LOSING WEIGHT AND
EXERCISE.
THIS IS -- I TOLD YOU THE GOOD
NEWS ABOUT THE STUDY.
THE BAD NEWS IS THAT WE FOLLOWED
THEM UP SEVEN MONTHS LATER AND
AFTER SEVEN MONTHS NOT ONLY HAD
THEY NOT -- CONTINUED TO LOSE
WEIGHT BUT THEY GAINED BACK MOST
OF THE WEIGHT THAT THEY LOST.
BASED ON THE FACT THEY REGAINED
THEIR WEIGHT, CAN A SIMILAR BUT
LESS EXPENSIVE APPROACH BE
APPLIED TO EXTENDED WEIGHT LOSS,
DEPOSIT CONTRACTS NO LONGER A
FIX PAYMENT OF $3, JUST A MATCH,
A PURE MATCH.
ONCE AGAIN, WE FOUND THAT THE
PROGRAM WAS SUCCESSFUL IN
GETTING PEOPLE TO LOSE WEIGH AND
KEEP THE WEIGHT OFF FOR EIGHT
MONTHS INSTEAD OF FOUR MONTHS
BUT ONCE AGAIN BAD NEWS WHEN WE
FOLLOWED THEM UP AT 17 MONTHS
THEY HAD REGAINED PRETTY MUCH
ALL THE WEIGHT THEY HAD LOST.
ANOTHER PROGRAM THAT WE DID, I'M
GOING TO END IN SEVEN MINUTES
BECAUSE I WANT TO HAVE AN
EXTENDED DISCUSSION.
ANOTHER PROGRAM THAT WE DID
INVOLVED INCENTIVES FOR
MEDICATION ADHERENCE USING DAILY
LOTTERIES.
THIS IS DONE WITH WARRAFARIN.
WARFARAN, A LOT OF YOU ARE
DOCTORS BUT IT'S A VERY
DANGEROUS DRUG IF YOU TAKE TOO
MUCH OF IT YOU CAN BLEED
INTERNALLY, DIE FROM INTERNAL
BLEEDING.
AND SO A LOT OF DOCTORS ARE
AFRAID OF PRESCRIBING WARFARIN
TO THEIR PATIENTS BECAUSE THOUGH
IT'S VERY BENEFICIAL, BECAUSE
IT'S SO DANGEROUS.
ADHERENCE IS SO POOR.
WE DESIGNED AN INTERVENTION TO
GET PEOPLE TO TAKE THEIR
WARFARAN, THE RIGHT AMOUNT OF
TIME, NOT TOO MUCH, NOT TOO
LITTLE.
AGAIN, IT'S EXACTLY THE SAME
LOTTERY THAT I TOLD YOU ABOUT
BEFORE AND AGAIN, WE PLAY ON
REGRET.
WE TELL THEM ABOUT THEIR
WINNINGS AND WE TELL THEM IF
THEY WON BUT DIDN'T TAKE THEIR
WARFARIN WE SAY TOO BAD WE WON
THE LOTTERY BUT BECAUSE YOU
DIDN'T TAKE WERE WARFARIN YOU
DIDN'T GET PAID.
HOW DO WE KNOW THEY TOOK THEIR
WARFARI ?RKS?
THE ANSWER IS BY NOW AN OLD
FASHIONED PIECE OF TECHNOLOGY,
THE TECHNOLOGY IS DEVELOPING
INCREDIBLY QUICKLY NOW BUT THIS
IS AN OLD PEACE CALLED A MEDE
MONITOR WHICH COMMUNICATES BY
TELEPHONE, COMMUNICATES WITH THE
PATIENTS AND ALSO GOT THESE
LITTLE COMPARTMENTS AND WHEN THE
PATIENT OPENS THE COMPARTMENT IT
SENDS US A MESSAGE.
SO WE KNOW AT LEAST -- WE DON'T
KNOW WHETHER THEY TOOK WARFARIN
BUT WHETHER THEY OPENED THE
COMPARTMENT.
MOST PEOPLE WHO ARE TAKING
WARFARIN ARE MOTIVATED TO TAKE
IT.
IF YOU HAD A STROKE, ABOUT 15%
CHANCE YOU'RE GOING TO HAVE
ANOTHER STROKE IN THE NEXT YEAR
IF YOU DON'T TRITE, YOU CAN
REDUCE THAT TO 3% IF YOU TAKE
YOUR WARFARIN, MOST PEOPLE DON'T
WANT TO HAVE A STROKE.
SO ON.
SO RATES OF NON-ADHERENCE TO
WARFARIN WERE REDUCED WITH THESE
LOTTERY BASED INCENTIVES QUITE
DRAMATICALLY.
THESE ARE THE INR RATES, PEOPLE
PROPERLY CO-ING ALATED.
YOU CAN SEE THEY WERE NOT
PROPERLY COAGULATED BEFORE
TREATMENT, MUCH MUCH BETTER
DURING THE TREATMENT, AND BUT
ONCE AGAIN, SAME MESSAGE AS THE
-- SAME MESSAGE AS FOR THE
WEIGHT LOSS, SOON AS WE REMOVE
THE INCENTIVE, THEY WENT BACK TO
THEIR OLD POOR RATES OF
ADHERENCE.
IN MY OPINION, ALL OF THIS --
YES.
(OFF MIC)
>> THIS IS SORRY, THESE ARE THE
BLOOD TESTS.
I SHOULD HAVE CLARIFIED THIS.
SO THESE ARE THE DATA FROM THE
MEDE MONITOR, THESE ARE DATA
FROM THE BLOOD TESTS.
SO IN MY OPINION A BIG ISSUE FOR
THESE TYPES OF INTERVENTIONS IS
HABIT FORMATION.
FOR SOMETHING LIKE THE HRA
COMPLETION, A ONE SHOT THING OR
FLU SHOT OR SOMETHING LIKE THIS,
THESE INTERVENTIONS SEEM TO WORK
REALLY WELL.
THEY ALSO WORK PRETTY WELL FOR
MORE DIFFICULT BEHAVIORS LIKE
WEIGHT LOSS AND MEDICATION
ADHERENCE BUT THERE'S A BIG
PROBLEM THAT AS SOON AS THE
INCENTIVE FOR ONGOING BEHAVIOR
CHANGE AS SOON AS INCENTIVES ARE
REMOVED.
SO FAR WE HAVEN'T BEEN ABLE TO
DEVELOP HABITS.
WE'RE DOING RESEARCH TO TRY TO
FIX THAT PROBLEM.
SO IN SUM, PREMIUM ADJUSTMENTS
FOR HEALTH BEHAVIOR ARE COMING,
THEY'RE PART OF THE HEALTHCARE
REFORM.
THEIR PITFALLS ARE CLEAR, THAT
IS, THEY'RE GOING TO INTRODUCE
GREATER REGRESSIVITY, POOR
PEOPLE WHO CAN LEAST AFFORD THE
PAY MORE FOR HEALTHCARE ARE
GOING TO BE PAYING MORE FOR
HEALTHCARE.
IT WOULD BE A TRAGEDY IF IT
DOESN'T HAVE THEIR INTENDED
EFFECT WHICH IS TO CHANGE
BEHAVIOR.
AND THESE IDEAS CAN BE USED TO
ENSURE THAT INCENTIVES FOR
HEALTHY BEHAVIOR INTRODUCED BY
HEALTHCARE REFORM WILL ACTUALLY
HAVE THEIR INTENDED IMPACT.
[APPLAUSE]
(OFF MIC)
>> THERE ARE A VARIETY OF MODELS
IN DIFFERENT COUNTRIES.
(OFF MIC)
>> YOUR QUESTION WORRIES ME
BECAUSE YOU BEGAN WITH SOMETHING
THAT'S EXACTLY THE OPPOSITE OF
THE POINT THAT I WAS TRYING TO
MAKE.
IN MY OPINION ALL OF THE -- THE
REALLY EFFECTIVE WAYS OF CUTTING
COSTS ARE EXACTLY DEAL WITH THE
BUSINESS MODEL.
THEY DEAL WITH A WAY THAT WE
ADMINISTER HEALTHCARE IN THIS
COUNTRY.
I DON'T THINK THAT THE ANSWER TO
THE HEALTHCARE COST PROBLEM IS
TO CHANGE BEHAVIOR.
ALL I WAS SAYING WAS THAT OF
COURSE CHANGING HEALTH BEHAVIOR
IS A VALID GOAL, IT COULD REDUCE
COSTS, ALL I'M SAYING IS THAT
THE SAFE WAY AMENDMENT IS GOING
TO HAVE NEGATIVE CONSEQUENCES
THAT MANY PEOPLE WOULD BE LESS
NEGATIVE, GOING TO INCREASE
REGRESSIVITY AND IT'S QUITE
LIKELY THE WAY -- VERY LIKELY
INTRODUCED IT'S NOT GOING TO
HAVE COMPENSATING BENEFITS.
THAT WE NEED TO THINK CAREFULLY
ABOUT HOW THE INCENTIVES ARE
INTRODUCED SO IT DOES HAVE
COMPENSATING BENEFITS.
BUT I VERY MUCH THINK CHANGING
HEALTHCARE BEHAVIORS IS NOT A
WAY TO REDUCE HEALTHCARE COSTS
IN THIS COUNTRY.
THAT WAS THE POINT OF THIS
SLIDE.
I THINK IT WILL HELP.
BUT THERE ARE OTHER -- THAT'S
NOT WHERE THE ACTION IS REALLY.
(OFF MIC)
>> -- IS THE ACTUAL PROFIT MODEL
(INAUDIBLE).
(OFF MIC)
>> RIGHT.
I WOULD SAY I WAS INTENDING
THESE TO COVER EXACTLY THE POINT
THAT YOU'RE MAKING.
I DO THINK A DIFFERENCE IN
BUSINESS MODEL WOULD AFFECT ALL
THESE THREE POINTS.
MICHAEL.
>> I'M CURIOUS WHAT YOUR
PRACTICAL EXPERIENCE HAS BEEN
(INAUDIBLE) IN ENVIRONMENTS THAT
ARE (INAUDIBLE) I'M ALL OVER
THIS (INAUDIBLE) INCLUDING
ACADEMIC SETTINGS INCLUDING IN
PITTSBURG AND PROPOSING TO
CLINICIANS AND NON-ECONOMISTS
(INAUDIBLE) LIKE THIS.
THAT PEOPLE IN MY LIMITED
EXPERIENCE OFTEN HAVE A
REFLECTIVELY ETHICAL RESPONSE OF
(INAUDIBLE) I'M CURIOUS DO YOU
HAVE THAT EXPERIENCE AS WELL?
>> WHEN I TOLD MY MOTHER, MY
MOTHER ASKED ME ABOUT THE
RESEARCH I DO.
AND WHEN I TOLD HER, H HE ACTION
WAS YOU'RE PAYING PEOPLE FOR
DOING WHAT THEY SHOULD BE DOING
ON THEIR OWN?
SHE WAS HORRIFIED.
AND I HAVE TO ADMIT THAT A PART
OF ME SHARES THE RESERVATIONS.
I DON'T THINK WE WANT TO WELD
INTO SOCIETY WHERE WE'RE PAYING
PEOPLE FOR DOING THE THINGS THAT
ARE GOOD FOR THEM.
SO I THINK FIRST THERE ARE A LOT
OF INCENTIVES BUILT INTO --
NEVADA TA BRING THERE ARE
INCENTIVES IN EVERY PLAN.
IF THEY ARE BUILT IN WE MIGHT AS
WELL IMPLEMENT THEM IN WAY
THEY'RE GOING TO HEP.
I DON'T THINK WE'RE GOING TO WAB
TO MOVE TO A -- WANT TO MOVE THE
A SOCIETY WE'RE INCENTIVIZING
PEOPLE TO DO DIFFERENT THINGS.
WE DON'T EPIKNOW FORGET THE
ETHICS.
WE DON'T EVEN KNOW WHR WHETHER
IT WILL BE EFFECTIVE.
ALL OF THESE EXPERIMENTS FOCUS
ON ONE BEHAVIOR.
WE HAVE NO IDEA WHAT WOULD
HAPPEN IF WE INCENTIVIZE
MULTIPLE BEHAVIORS.
SO I SHARE THOSE PSYCHOLOGISTS
OR CLINICIANS RESERVATIONS AND
MY MOTHER'S RESERVATIONS.
ON THE OTHER HAND, TAKE
SOMETHING LIKE AGAIN HIGGINS, A
PSYCHOLOGIST WHO DOES A LOT OF
THIS WORK, HE'S DONE A BUNCH OF
WORK TARGETING PREGNANT
TEENAGERS WHO SMOKE.
AND INCENTIVIZING THEM TO NOT
SMOKE.
THAT TO ME SEEMS
NON-CONTROVERSIAL.
IT'S VERY EFFECTIVE.
OTHER TYPES OF APPROACHES
HAVEN'T BEEN PROVEN TO BE
EFFECTIVE.
SO I THINK TARGETED INCENTIVES
TO THE RIGHT PEOPLE IN THE RIGHT
CIRCUMSTANCES CAN BE DESIRABLE
AND BENEFICIAL.
I SHARE THESE ETHICAL QUALMS
YOU'RE MENTIONING.
RICHARD.
(OFF MIC)
>> CERTAINLY THERE'S A LOT OF
LOW HANGING FRUIT WHEN IT COMES
TO DEFAULT AND NUDGES THAT DON'T
COST ANYTHING M AND WE SHALL GO
AS FAR AS WE CAN WITH THOSE IN
MY OPINION.
BUT TAKE SOMETHING LIKE WARFARIN
ADHERENCE, HOW DO YOU DEFAULT
SOMEBODY TO TAKE THEIR CORRECT
AMOUNT OF WARFARIN.
SO THOSE ARE SITUATIONIOUS MIGHT
NEED OTHER INTERVENTIONS LIKE
POSSIBLY UNSENTIVE BASED
INTERVENTIONS.
IN OUR RESEARCH WE ATTEMPTED TO
LIKE TAKE THE WARFARIN CASE, HOW
DO WE CHOOSE $3 EXPECTED VALUE A
DAY, WE DID A CASUAL ESTIMATION
HOW MUCH IT WOULD SAVE TO GET
SOMEBODY NON-ADHERENT TO
WARFARIN TO BECOME ADHERENT.
SO THE $3 A DAY IS VERY
CONSERVATIVE ESTIMATE.
TAKE THE HEALTHCARE REFORM.
THAT DOESN'T COST ANYTHING.
THAT'S GETTING PEOPLE WITH POOR
HEALTH BEHAVIORS TO PAY MORE AND
PEOPLE WITH GOOD HEALTH
BEHAVIORS TO PAY LESS SO WE
DON'T HAVE TO WORRY ABOUT COST
EFFECTIVENESS THERE, ALL WE HAVE
TO WORRY ABOUT IS EFFECTIVENESS.
(OFF MIC)
>> THE WHOLE FIELD?
(OFF MIC)
I THINK THERE'S GOING TO
CONTINUE TO BE RESEARCH ON
DEFAULTS AND NUDGES.
I THINK WE STILL HAVE FURTHER TO
GO.
WE DID A PROGRAM, COLLABORATION
WITH CDS WHERE WE GOT PEOPLE TO
USE DEFAULTS.
WE ACTUALLY NOT USING DEFAULTS
BUT USING FORCED CHOICE.
FORCING PEOPLE TO MAKE A CHOICE.
WE HAVE HUGE INCREASE IN PEOPLE
DOING MALE ORDER OVER GOING TO
THE PHARMACY.
SO THERE'S A BIG SCOPE FOR THAT.
BUT THE BIG SHORT TERM ISSUE IS
THE ISSUE THAT I RAISED.
HOW CAN WE INCULCATE HABITSCH
BECAUSE WE DON'T WANT TO BE
INTRODUCING LONG TERM INCENTIVES
FOR TOO MANY BEHAVIORS.
YES.
(OFF MIC)
>> THAT WAS A ONE SHOT
COMPLETING THE HRA.
I'M GLAD YOU RAISED THAT BECAUSE
IT GIVES ME A BETTER ANSWER TO
DR. SUZMAN'S QUESTION, THAT IS,
SO FAR WE MAINLY HAVE BEEN DOING
INDIVIDUALISTIC REWARDS.
BUT I COMPLETELY AGREE WITH YOU
THAT A REALLY IMPORTANT NEW AREA
FOR RESEARCH BOTH WITH
INCENTIVES AND WITHOUT
INCENTIVES IS KIND OF GROUP
REWARDS, GROUP PRESSURE AND SO
ON.
WE JUST DID A INTERVENTION,
HOPEFULLY ABOUT TO GET ACCEPTED
FOR PUBLICATION WITH DIABETES
AISH PATIENTS COMPARING MONETARY
REWARD PROGRAM TO THE PEER
MENTOR PROGRAM.
SO WE TOOK SOMEBODY WHO HAD OUT
OF CONTROL DIABETES AND THEY HAD
GOTTEN IT UNDER CONTROL, THEY
WERE THE MENTOR AND THEY WORKED
WITH SOMETHING WHO DIDN'T HAVE
IT UNDER CONTROL.
AND THE PEER MENTOR PROGRAM WAS
EFFECT TREATMENTLY EFFECTIVE,
MORE EFFECTIVE THAN THE
INCENTIVE PROGRAM.
SO I AGREE WITH YOU THAT GROUPS,
DYADS AND SO ON IS A REALLY
IMPORTANT NEW AREA WITH AND
WITHOUT INCENTIVES.
THAT'S ANOTHER AREA WE SHOULD BE
GOING INTO IN THE FUTURE.
YES.
(OFF MIC)
>> I MEAN, THE INSURANCE
COMPANIES ARE ENORMOUSLY
INTERESTED IN THIS.
AND WE'RE WORKING WITH A RANGE
OF INSURANCE COMPANIES TO TEST
INTERVENTIONS LIKE THIS WITH
THEIR POPULATIONS.
ALSO WE'RE DOING THIS WORK WITH
CVS PHARMACY BENEFITS MANAGER.
SO THERE'S ENORMOUS COMMERCIAL
INTEREST.
MAYBE THERE'S NOT AS MUCH
INTEREST AS THERE COULD BE, AND
THE REASON FOR THAT WOULD BE
THAT IN TODAY'S FRAGMENTED
HEALTHCARE MARKET, THIS GOES
BACK TO YOUR POINT, WHERE PEOPLE
ARE CHANGING JOBS AND CHANGING
INSURERS ALL THE TIME, AN
INSURER WHO SPENDS MONEY TO
CHANGE AN EMPLOYEE'S HEALTH
BEHAVIOR IS LIKELY TO NOT
ACTUALLY CAPTURE THE GAINS FROM
THE IMPROVEMENT IN HEALTH.
SO THAT'S ANOTHER BIG
DISADVANTAGE OF THE WAY THAT WE
DO THINGS NOW.
THERE IS A HUGE INTEREST IN
INSURERS DESPITE THAT FACT IN
THESE INTERVENTIONS IN THE BACK.
(OFF MIC)
>> WE ARE.
WE'RE DOING A LOT OF RESEARCH ON
THAT.
AND THAT IS MORE IN PROGRESS.
SO THAT'S WHY I DIDN'T TALK
ABOUT IT.
BUT I AGREE, IT'S VERY IMPORTANT
AREA AND THE -- A SPECIFIC --
ONE FOCUS IN THAT RESEARCH IS ON
THE IMPACT OF LIMITING CONFLICT
OF INTEREST, WHAT'S THE IMPACT
OF REDUCING CONFLICT OF INTEREST
ON PHYSICIAN BEHAVIOR BUT ALSO
LOOKING AT THE IMPACT OF LIKE
FOR EXAMPLE IN DIABETES
MANAGEMENT WE'RE COMPARING THE
IMPACT OF INCENTIVIZING PATIENT,
INCENTIVIZING PHYSICIANS,
INCENTIVIZING BOTH OR NEITHER.
I COMPLETELY AGREE, THAT'S
ANOTHER YOU'RE ALL GIVING ME
GOOD RESPONSES TO DR. SUZMAN'S
QUESTION, ANOTHER 'ALLY
IMPORTANT AREA OF FUTURE
RESEARCH.
(OFF MIC)Csrp
>> I'M TRYING TO BE DIRECT WITH
YOU ABOUT THE GOOD AND BAD
THINGS.
BUT NEVERTHELESS, FIRST THERE'S
A LOT OF THINGS IN HEALTHCARE
THAT ARE ONE SHOT LIKE
VACCINATIONS.
AND COMPLETING HRAs AND SO ON.
THESE APPROACHES ARE VERY
EFFECTIVE FOR THOSE.
SECOND ALL OF OUR INTERVENTIONS
HAVE BEEN PERSISTENTLY EFFECTIVE
AS LONG AS WE KEPT INCENTIVES
GOING.
SOME ARE QUITE COST EFFECTIVE.
SO YOU COULD SAY FINE, LET'S --
WHERE IT'S REALLY IMPORTANT
LET'S KEEP THE INCENTIVES GOING
AS LONG AS WE WANT TO CHANGE THE
BEHAVIOR.
YOU'RE RIGHT.
THE WEAK POINT IS THAT WE DON'T
YET KNOW HOW TO DEVELOP PROGRAMS
WHERE WHEN WE REMOVE THE
INCENTIVES THE BEHAVIOR
PERSISTS.
>>
(OFF MIC)
>> WELL, WE HAVE FOUR MONTHS
VERSUS EIGHT MONTH WEIGHT LOSS
AND ALSO I THINK THESE
INCENTIVES ARE DESIGNED TO HAVE
A PERSISTENT EFFECT BUZZ THEY
INVOLVE A LOT OF INTERACTION
BETWEEN THE CLINICIAN AND THE
PATIENT.
THE PATIENT KEEPS PUTTING THE
MONEY DOWN OR KEEPS GETTING
THESE MESSAGES, YOU WON $100
TODAY BUT YOU DON'T GET IT, SO
ON.
THOSE ARE PRETTY COMPELLING
MESSAGES.
(OFF MIC)
>> THAT'S RIGHT.
WE DON'T HAVE EVIDENCE BEYOND 8
MONTHS BUT WE'RE OPTIMISTIC ON
THAT POINT.
YES.
>> THERE IS RESEARCH GOING ON,
I'M NOT AN EXPERT ON RESEARCH
FUNDING AND THINGS LIKE THAT BUT
THERE IS RESEARCH GOING ON IN
MEDICARE, MEDICAID.
TRYING TO DO FIELD STUDIES TO
TEST THE IMPACT OF THESE TYPES
OF INTERVENTIONS MOST STUDIES
ARE REAL PEOPLE IN REAL
SITUATIONS.
THERE ARE SOME METHODS THAT WE
CAN EMPLOY, LIKE INTERRUPTED --
CRUDE INTERRUPTED TIME SERIES TO
SEE IF THESE MEASURES HAVE AN
IMPACT.
BUT SO MANY THINGS ARE CHANGING
AT THE SAME TIME THAT YOU'RE
RIGHT WE'RE NOT GOING TO REALLY
KNOW EXACTLY WHAT -- IF WE GET
CHANGES IN BEHAVIORS WE'RE NOT
GOING TO KNOW EXACTLY WHAT
DRIVES THEM.
LET ME SAY THAT I DO THINK THAT
THE -- A LOT OF THE PIECES OF
THE HEALTHCARE REFORM ACT ARE
NOT EVIDENCE-BASED.
SO THE CALORIE POSTING, MAYBE
PEOPLE -- PEOPLE PERHAPS YOU
COULD ARGUE PEOPLE DESERVE TO
HAVE INFORMATION WHEN THEY MAKE
FOOD CHOICES, THEY DESERVE --
IT'S AN INHERENT GOOD TO HAVE
THE INFORMATION UP THERE SO YOU
KNOW HOW MANY CALORIES YOU'RE
TAKING IN.
BUT THERE'S NO EVIDENCE THAT
THAT'S GOING TO HAVE ANY
POSITIVE IMPACT ON BEHAVIOR.
SAME THING WITH V BED, SAME
THING MY WHOLE TALK WAS ABOUT,
SAME THING WITH THE CONTINGENT
INSURANCE PREMIUMS, WE HAVE NO
-- WE HAVE NO EVIDENCE THAT
THAT'S ACTUALLY GOING TO HAVE A
BENEFICIAL EFFECT.
SO PRETTY MUCH ALL OF THE PIECES
OF THE HEALTHCARE REFORM ACT
THAT ARE DESIGNED TO CHANGE
HEALTH BEHAVIORS ARE NOT
EVIDENCE BASED.
YOU'RE RIGHT.
WE'RE NOT GOING TO GET DATA WHEN
THE ACT IS IMPLEMENTED.
WE'RE GOING TO NOT GET USABLE
INFORMATION ABOUT WHAT THE
IMPACTS ARE.
THAT'S WHY WE NEED TO DO MORE
RESEARCH OF THIS TYPE.
(OFF MIu!f…
>> THAT'S RIGHT.
SOMETHING I DIDN'T GO INTO
DETAIL ABOUT ON THE WARFARIN.
WE IMPLEMENTED THE INCENTIVES
WRONG THE FIRST TIME WE DID IT.
IT WAS $5.
$5, RARE THAN $3 WHICH IS WHAT
WE INTENDED.
5DZ WAS EFFECTIVE BUT WE STARTED
OVER AGAIN, WE CONTINUED THOSE
PEOPLE AND STARTED OVER AGAIN
WITH A NEW GROUP, $3 A DAY.
IF ANYTHING CERTAINLY THERE'S NO
SIGNIFICANT DIFFERENCE BUT AT $3
A DAY WAS JUST AS EFFECTIVE
AS $5.
WHAT IF WE DID $3 IS WHAT WE
THINK IS ALMOST CERTAINLY COST
EFFECTIVE?
BUT WHAT IF WE WENT --
(OFF MIC)
>> IF YOU LOOK AT THE BLOOD --
YEAH, THAT'S RIGHT.
THAT'S RIGHT.
$3 -- THE $5 LOOKS
PROPORTIONATELY MORE SUCCESSFUL.
THIS IS A SMALL -- THIS IS A
SMALL STUDY.
I WOULD NOT -- BUT THE POINT IS
WEP,ã DONE KNOW HOW LOW WE CAN GO.
$3 IS ALREADY -- SO I COMPLETELY
AGREE WITH YOUR QUESTION OF
COURSE.
BUT $3 IS PROBABLY ALREADY COST
EFFECTIVE BUT IT MIGHT BE A
PROGRAM INVOLVING $1 A DAY WOULD
BE EFFECTIVE AND BE WAY MORE
COST EFFECTIVE.
(OFF MIC)
>> I AGREE, THAT WOULD BE A
GREAT DIRECTION TO GO.
WE ARE DOING SOME INTERVENTIONS
TO TRY TO DEVELOP HABITS THAT DO
PLAY ON PSYCHOLOGY BUT NOT
EXACTLY WHAT YOU ARE TALKING
ABOUT.
BACK TO YOU.
(OFF MIC)
>> WE HAVEN'T.
THERE'S A WEBSITE CALLED
STICK.COM AND THEY USE THAT.
ON THE OTHER HAND --
(OFF MIC)
>> THEY DON'T HAVE ANY DATA
BECAUSE IT'S THEIR COMMERCIAL
WEBSITE.
BUT THEY -- I THINK THOSE TYPES
OF IDEAS MIGHT BE VERY PROMISING
BUT YOU WOULD CERTAINLY WANT TO
COMBINE THEM WITH SOME OF THE
IDEAS IN OUR WORK LIKE FOR
EXAMPLE, THE DAILY DEPOSIT,
THINGS LIKE THAT.
I THINK THESE PROGRAMS WHERE YOU
PUT MONEY DOWN AND YOU HAVE A
LISTENING TERM GOAL ARE LESS
EFFECTIVE THAN THE TYPES OF
PROGRAMS WE DO WHERE YOU GET
DAILY FEEDBACK.
(OFF MIC)
>> PERHAPS.
(OFF MIC)
>> THE ONLY STUDY THAT I KNOW OF
ON THIS, WE DID.
AND I HAVE OFTEN HEARD THAT
CLAIM.
BUT I THINK THAT WE DID THE ONLY
STUDY -- WE DID THE ONLY STUDY
THAT I KNOW OF EXACTLY ON THIS.
WE WENT TO NEW YORK CITY BEFORE
THEY INTRODUCED CALORIE POSTING
AND FAST -- IN FAST FOOD
RESTAURANTS.
WE COLLECTED MEAL RECEIPTS.
AND EVEN DURING THAT TIME WE
RANDOMLY ASSIGN PEOPLE TO GET NO
CONTEXTUAL INFORMATION TO GET
THIS IS HOW MANY CALORIES YOU
SHOULD EAT PER DAY, THIS IS HOW
MANY CALORIES YOU SHOULD EAT FOR
LUNCH.
IT WAS LUNCH.
VERY, VERY TARGET -- TARGETED
CONTEXTUAL INFORMATION.
WE WENT BACK AFTER CALORIE
POSTING A MONTH LATER AND WE HAD
SAME THREE GROUPS.
GIVING THEM THE CALORIE
CONTEXTUAL INFORMATION
BENEFICIAL EFFECT.
EVEN DAILY, WE EXPECTED THAT IT
WOULD.
THIS IS HOW MANY CALORIES YOU
SHOULD EAT FOR LUNCH SO YOU CAN
COMPARE THE TWO.
DAILY IT'S MORE DIFFICULT.
BUT WE HAD NO IMPACT.
(OFF MIC)S!
>> GREAT POINT.
I'M PESSIMISTIC IF YOU TAKE A
PERSON BEFORE YOU GO INTO
MCDONALDS BEFORE AND AFTER
CALORIE POSTING TO HIRE GOING TO
ORDER A DIFFERENCE -- THAW EAR
GOING TO EAT A DIFFERENT --
THEY'RE GOING TO EAT A DIFFERENT
MEAL.
MAYBE SOME WILL BUT PROBABLY NOT
THE PEOPLE WE CARE ABOUT.
I'M A LITTLE BIT MORE OPTIMISTIC
ABOUT THE IDEA THAT MAYBE A FEW
PEOPLE WILL NOT GO TO MCDONALD'S
AND MAYBE GO TO SUBWAY OR
SOMETHING LIKE THAT.
(OFF MIC)
THAT'S THE THIRD POINT.
THE BIGGEST AREA WHERE THIS
MIGHT HAVE A BENEFIT IS IF
MCDONALDS, IT'S A TELL-TELL
HEART EFFECT, MCDONALD'S AN
SUBWAY GET -- THE INFORMATION IS
OUT THERE NOW, WE HAVE TO CHANGE
OUR MENU.
GENERALLY, I HAVE DONE A LOT OF
RESEARCH ON DISCLOSURE AND THE
READING THAT I HAVE DONE,
DISCLOSURE OF INFORMATION, FOR
EXAMPLE, DISCLOSURE OF CONFLICTS
OF INTEREST, MOST OF THE
LITERATURE ON DISCLOSURE SHOWS
THAT TO THE DEGREE DISCLOSURE
HAS AN EFFECT, A BENEFIT, AND IT
OFTEN DOES HAVE A BENEFIT, IT
DOESN'T OPERATE THROUGH THE
CONSUMER.
IT OPERATES THROUGH THE
RETAILER, THE PRODUCER AND SO
ON.
I THINK THAT'S TRUE HERE TOO.
IF CALORIE POSTING HAS A
BENEFIT, ALMOST FOR SURE THE
BIGGEST BENEFIT WILL BE IF IT
CHANGES THE -- WHAT THE
OFFERINGS OF THE FAST FOOD
RESTAURANTS.
YES.
(OFF MIC)
>> I TOTALLY AGREE WITH YOU,
IT'S NOT JUST ABOUT THE MONEY.
IT'S NOT -- ALSO IT'S NOT ABOUT
-- ONLY ABOUT THE TYPES OF
ISSUES THAT I HAVE DISCUSSED BUT
ALSO ABOUT THE SYMBOLIC VALUE.
FOR EXAMPLE, WHO IS -- WHO IS
GIVING YOU THE MONEY?
IF IT'S A HEALTH INSURER YOU
MIGHT FEEL LIKE THEY'RE DOING IT
FOR THEIR BENEFIT, IT'S NOT FOR
ME BUT MAYBE IF IT'S YOUR
EMPLOYER IF YOUR EMPLOYER GIVING
IT TO YOU IF YOU HAVE A GOOD
RELATIONSHIP WITH YOUR EMPLOYER
MAYBE YOU FEEL LIKE THEY'RE
DOING IT FOR ME NOT DOING IT TO
SAVE MONEY.
THE ISSUE ONCE YOU START
THINKING ABOUT THE SYMBOLIC
SIGNIFICANCE, THEN THINGS LIKE
WHO DOES THE MONEY COME FROM
COULD POTENTIALLY MAKE A BIG
DIFFERENCE.
SO I AGREE, THAT'S SOMETHING WE
REALLY NEED TO THINK CAREFULLY
ABOUT.
NOT ONLY INCENTIVE VALUE BUT
WHAT'S THE MEANING OF THE MONEY.
(OFF MIC)
>> GIVING PEOPLE THOUSANDS OF
POINTS, YEAH.
(OFF MIC)
>> CERTAINLY.
THERE'S CERTAINLY A LOT OF
RETAILERS SEEM TO BELIEVE THAT
THAT IS AN EFFECTIVE STRATEGY.
I WONDER WHETHER ITS
EFFECTIVENESS MIGHT BE LOWER NOW
THAN IT WAS WHEN THEY STARTED
DOING IT.
I THINK A LOT OF PEOPLE ARE
CYNICAL ABOUT POINTS FROM THEIR
OWN EXPERIENCE WITH TRYING TO
REDEEM THEM.
WE HAVE ACTUALLY IN A COMPLETELY
DIFFERENT LINE OF RESEARCH, WE
WORKED WITH A BANK ON LOYALTY
PROGRAMS.
THE BANK CUSTOMERS ARE
FRUSTRATED BY A PROGRAM LIKE
THAT.
WE STARTED GIVING THEM SURPRISE
GIFTS.
THEIR LOYALTY TO THE BANK AND
THEIR DEPOSITS WENT UP WHEREAS
FOR THE THE CONTROL GROUP THEY
WENT DOWN.
SO I THINK THAT THESE KIND OF
LOYALTY PROGRAMS AND POINTS AND
THINGS LIKE THAT, PEOPLE ARE
BURNT OUT ON THEM.
SO THERE MIGHT HAVE BEEN A TIME
WHEN THAT WOULD BE A GOOD IDEA
BUT I THINK BASED ON INTUITION,
IT MAY HAVE PASSED.
YOU HAVE TO TELL ME WHEN --
>> PROBABLY SOON.
>> OKAY.
SURE.
>> YOU ALLUDED TO I GUESS
HIGGINS DATA USES YOUNGER
PEOPLE, ADOLESCENTS.
BUT IN GENERAL HOW DOES THIS
WORK IN KIDS?
WOULD IT BE MORE EFFECTIVE TO
USE INCENTIVES, LESS, OR MIGHT
HAVE HELPED THEM AND STILL HAVE
IT OR ARE THEY NO DIFFERENT FROM
ADULTS?
>> PROBABLY -- WELL, FIRST OF
COURSE INCENTIVES ARE USED A LOT
WITH KIDS.
THERE'S SOME VERY INTERESTING
STUDIES INVOLVING PAYING KIDS
FOR SCHOOL WORK.
AND TURNS OUT THAT IT'S MUCH
BETTER TO PAY -- IT MIGHT HAVE
BEEN LISTENING TO NPR, WHAT'S
THE ECONOMIST NAME?
ROLAND FRIAR AT HARVARD.
HE'S BEEN DOING THESE PROGRAMS.
HE FINDS IF YOU PAY THE KIDS FOR
READING A BOOK OR FOR CONCRETE
BEHAVIOR SHOWING UP AT SCHOOL,
THAT'S QUITE EFFECTIVE.
IF YOU PAY THEM TO GET GOOD
GRADES, THAT HAS NO IMPACT AT
ALL.
SO THERE ARE CERTAINLY
INCENTIVES CAN BE VERY EFFECTIVE
WITH KIDS.
WITH CHILDREN YOU MIGHT WANT --
IF YOU DONE KNOW HOW TO GET GOOD
GRADES IT'S BETTER TO
INCENTIVIZE THE BEHAVIORS.
ADULTS MIGHT HAVE A BETTER IDEA,
WE INCENTIVIZE PEOPLE TO LOSE
WEIGH.
WE DIDN'T INCENTIVIZE PEOPLE TO
EXERCISE OR CUT DOWN ON EATING
BECAUSE WE FIGURED ADULTS KNOW
HOW TO LOSE WEIGHT.
THESE THINGS ARE DIFFICULT TO
MEASURE.
BUT MY READING OF THE LITERATURE
ON INCENTIVES FOR KIDS IS IT HAS
EXACTLY, IT'S CONFRONTING THE
ISSUES THAT HAVE -- OF HABIT
FORMATION.
INCENTIVES CERTAINLY ARE VERY
POWERFUL FOR KIDS.
I DO THINK THAT THERE'S SOME
WORK ON CROWDING OUT INTRINSIC
MOTIVATION F YOU PAY CHILDREN TO
DO ] THINGS THEY WON'
T BE
MOTIVATED TO DO THEM ON THEIR
OWN.
MY OWN VIEW IS THAT IS A BIT
OVERBLOWN.
AND THAT CHILDREN, ALL OF US, WE
LOVE DOING THINGS WE'RE GOD AT
AND WE HATE DOING THINGS THAT
WE'RE BAD AT.
SO IF YOU CAN GET SOMEBODY -- IF
YOU CAN PAY SOMEBODY TO DO
SOMETHING TO THE POINT WHERE
THEY BECOME COMFORTABLE WITH IT,
WHERE THEY GAIN MASTERY, THAT
CAN BE A HUGE EFFECT.
VERY LIKELY MUCH MORE POWERFUL
EFFECT THAN CROWDING OUT OF
INTRINSIC MOTIVATION THAT'S BEEN
SHOWN IN STUDIES WHERE
EVERYTHING ELSE IS HELD
CONSTANT.
OKAY.
MAYBE WE SHOULD --
[LAUGHTER]
>> I'LL ANSWER YOUR QUESTION
PERSONALLY.
>> OKAY.
SO PLEASE JOIN ME IN THANKING
GEORGE FOR A GREAT TALK.