Incentivizing Health Promotion: This TIME is somehow different from the last TIME.

by James Porter May 20, 2013

It was a David and Goliath moment that one seldom gets to see anywhere, let alone at a small health promotion conference (The American Journal of Health Promotion Conference to be exact) in the back of a small seminar room in Hilton Head, South Carolina. Michael Roizen, M.D., a giant in the healthcare industry who is a division head of the world renowned Cleveland Clinic and coauthor of the "YOU" series of books is sitting in the back of the room and a little known adjunct assistant professor from Michigan State University, Dr. Jonathan Robison is standing in the front. At issue, among other things, is a Time Magazine cover story about the high cost of healthcare entitled "Why Medical Bills are Killing Us."

Michael Roizen, M.D., of the Cleveland Clinic vs. Jonathan Robison, Ph.D., of Michigan State Univ.

This was a small breakout session with about fifty people in the room. But, tellingly, many of the major players from the world of health promotion were sitting there, including Dr. David Hunnicutt, President of Welcoa, Dr. Michael O'Donnell, Editor of The American Journal of Health Promotion and the conference organizer, and Dr. Paul Terry president of Staywell Health Management waiting to hear what Dr. Robison had to say. Dr. Roizen had, in the previous hour, just been addressing the entire conference, to a standing room only audience of maybe 600 plus people.

Dr. Robison goes around the country giving lectures about how the health care industry has got it wrong about obesity and how the Health Promotion industry has got it wrong about how to "incentivize" the kinds of changes in behavior that would combat it. Robison doesn't mind ruffling a few feathers in order to make a point. As he talks, he waves his arms, raises his voice, rolls his eyes, reads long lists of side effects from common medications, tells jokes about the health care industry and even asks his audience to shout out in unison: "R U Kidding me?"

Like a typical outsider to mainstream medicine, he decries the way things are in health care today. But like an insider, he quotes line and verse from study after study published in medical journals for every significant point he tries to make. He is particularly opinionated about incentives. He believes they don't work over the long haul. Needless to say, his opinions rub a lot of people the wrong way. The majority of people you talk to at the conference, take umbrage with his information and his sources. Dr. Terry, in the wrap up to the conference would later describe Robison's talk "as a lot of [inaccurate] conclusions based on [inaccurate] science."

Roizen had just gotten done telling the whole conference that incentives DO work. His proof was convincing. As the result of a major health promotion campaign at Cleveland Clinic, which featured a $2000 annual incentive, the entire employee population, which is the size of a small city, had been able to bring about reductions in health care costs through improvements in their overall health. Every employee at Cleveland Clinic can qualify for this reward by achieving certain health objectives built around no tobacco use, lowering stress, and maintaining certain glucose, blood pressure and weight levels.

The real issue isn't incentives per se, but whether these incentives are intrinsic or extrinsic. Robison presumably has no problem with intrinsic motivation. These are the behavior changes people make because it feels good to make them, like walking every day. They like doing it, and because it brings them pleasure, they continue doing it. It's when you pay people to make behavior changes that Robison has a problem. These changes are the ones that are inspired extrinsically. According to the research he quotes, these kinds of programs ultimately fail: when you stop paying, people stop playing.

According to Roizen the potential consequences of simply ignoring this issue are huge: Our nation's total health care bill right now represents 19% of our GNP. "We can not sustain this kind of drain on our economy." Roizen proclaims. Once it gets to 24%, a number we will likely arrive at in the next few years, Roizen believes that health care will have to be rationed and that the US economy will be badly compromised.

Dr. Terry facilitated a small meeting at the end of the second day of the conference to talk about incentives. One of the attendees and a speaker at the conference, Dr. David Anderson, suggested that three major behavioral changes that had occurred in the US were the result of a hybrid of extrinsic and intrinsic motivation. Littering, seat belt use and giving up tobacco had initially been launched by extrinsic incentives. (A fine for not using a seat belt extrinsically motivates the person to make the change.) Eventually as compliance with the new behavior grows, public opinion around the activity changes and social pressure to conform takes over, and the extrinsic motivation becomes intrinsic.

Robison was pushing a lot of people's buttons during his talk about incentives. This is an industry that wants desperately to believe that the truths it holds so dear are self-evident. And this industry runs on incentives. The most common incentives are the ones offered up for people who take biometric screenings and HRA's (health risk appraisals). The belief here is that these simple tests and screenings promote health by making the person more aware of both the risks and rewards of their current behaviors. The assumption is that it gets them to make changes based on what they find out from these screenings.

In the small group that was facilitated by Terry, participants (mostly wellness professionals) complained that "employees want to get paid for every healthy thing they do now." Typically people are rewarded, with reductions in the cost of their premiums but occasionally, with actual cash. Usually a participant in an incentive program gets points for engaging in healthy activities and must do a certain number of these activities in order to qualify for whatever reward is being offered. One of the wellness professionals working at a college told the story about an annual event where people jump into a freezing cold lake in the middle of winter. "Will that count toward my wellness goals?" one of his clients asked.

Robison comes down hard on the position that these kinds of incentives don't work. That people simply stop doing the behavior once you stop paying them to do it. And of course Roizen says just the opposite. Roizen's conclusions, as Paul Terry later pointed out, are based on his OWN research conducted in a world class medical institution. "Robison cherry picks articles no matter how obscure in support of the points he wants to make. Such an imbalanced literature review makes it difficult to dispute when only one side of the argument is being reviewed and presented."

The Time Magazine cover in question. Both speakers showed this same image in their power points.

But the David and Goliath moment came toward the end of the program when Robison flashed the same Time Magazine cover that Roizen had shown in the previous lecture. When Roizen displayed it, he claimed that the reason health care costs were so high was because, among other things, America is a nation of unhealthy, overweight people. Roizen concluded that it was the health of Americans not healthcare that is costing us billions. And furthermore, with the proper coaching, and the right incentives, the health of Americans could be dramatically improved and consequently, our healthcare bills could be dramatically lowered. And this sums up the goal of this whole conference.

Robison takes the position that the healthcare industry is selling Americans a bill of goods: By incentivizing dieting, for example, when, according to Robison, everyone knows the evidence clearly shows that diets don't work. "Not only do dieters gain back most of the weight they've lost within two years, many dieters ultimately gain weight as the result of dieting." Roizen, patiently listened to all of Robison's sometimes, diametrically opposed positions, calmly sipped his water bottle, and occasionally made comments to O'Donnell who was standing right behind him. That's when Robison put up the very same Time Magazine Cover that Roizen had used in his presentation.

Robison got pretty fired up when he started talking about that cover story. To almost the same degree that Roizen disagreed with the story's conclusion, Robison supported it. He spoke about how true the article was and how it accurately revealed everything that was wrong with our medical system today. "I've got the hospital bills from my 10 year battle with MS to prove it," Robison shouted out, apparently having experienced extraordinarily high medical bills, first hand. It was an emotional moment and you could feel the lines being drawn down the center of the room between those in favor of his position and those against.

Just when it looked like a confrontation between the two men seemed inevitable, Roizen, got up and quietly left the room. When asked later, if Robison knew that Roizen was there, Robison said "No, I wouldn't recognize him if I saw him."

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