USA TODAY

May 21, 2009

Cash Incentives Won’t Make Us Healthier

By Alfie Kohn

[This is an expanded version of the published article.
Click here for a 1-hour audio presentation by Kohn on this topic.]

In its first salvo at reforming health care, Congress is reportedly considering legislation that would do two things:  help employers to set up wellness programs and encourage the use of financial incentives to promote healthier living.

The first idea is terrific.  The second one is terrible.

Programs that reward employees who lose weight or stop smoking are already fairly common. A National Business Group on Health (NBGH) survey found that 30-40 percent of companies now offer such incentives.

Some critics say this amounts to corporate intrusion into employees’ private lives.  But there’s a more fundamental problem:  Paying people to become healthy simply doesn’t work, at least not in the long run. Regardless of whether the goal is to increase quality of life or hold down costs, incentives are mostly ineffective — and may even be counterproductive.

In 2007, the Center on Budget and Policy Priorities reported that “published research does not support the idea that financial incentives are effective at getting people to stop smoking.”  The following year, an academic review of the available data agreed:  “Smokers may quit while they . . . receive rewards for quitting, but do no better than unassisted quitters once the rewards stop.”

Likewise, an NBGH summary of weight-loss research in 2007 concluded that the promise of a reward may induce people to join a program but there is “no lasting effect” in terms of slimming down.

Have newer studies had better luck with incentives, as press reports suggest?  Last December, researchers supposedly found that people lost more weight if paid to do so.  But the small, poorly designed study showed no statistically significant difference at the final weigh-in.  A study of incentives and smoking published earlier this year produced a similar discrepancy between breathless news accounts and unimpressive actual findings.

By contrast, three better-designed experiments – in which various kinds of training and support were provided for quitting smoking – discovered that the effectiveness of these interventions was reduced if a reward was offered for kicking the habit.  In some cases, people promised money actually fared worse than those who weren’t in a program at all!

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If these results seem surprising, it may be because of how we tend to think about motivation – namely, as something that goes up when we’re offered a dollar, an A, or a “Good job!”  But psychologists now realize that there are different types of motivation — and the type matters more than the amount.

“Extrinsic” motivation (to get a reward or avoid a punishment) is much less effective than “intrinsic” (a commitment to doing something for its own sake).  What’s more, the two are often inversely related.  Scores of studies confirm that the more we’re rewarded for doing something – at work, at school, or at home — the more we’re apt to lose interest in whatever we had to do to get the reward.

Thus, a study in last November’s Developmental Psychology showed, as did two previous experiments, that children who are rewarded for helping or sharing subsequently become less helpful.  Similarly, the more that students are led to focus on getting good grades, the less interesting they come to find the learning itself.  They also think less deeply on average than students who aren’t graded.

Adjusting the size, type, or scheduling of the incentive doesn’t help because the problem is with the outdated theory of motivation on which all rewards are based.  Unfortunately, that psychological theory is still accepted by most economists – including those in the trendy field of behavioral economics – who, in turn, influence public policy.

Sure, bribes and threats can produce temporary compliance.  Offer a reward to adults for going to the gym, or to children for picking up a book, and it may work — for awhile. But they come to think of themselves as extrinsically motivated, so when the reward is no longer available there’s no reason to continue.  Indeed, they may wind up less interested in exercising or reading than they were before.

Rewards have been called “sugar-coated control.”  We like the money — or the candy or the praise – but we resent being manipulated with it.  Also, rewards are based only on observable behaviors.  They ignore the reasons we may turn to food or cigarettes for solace.

“Smoking, drinking, overeating, or not exercising often represent coping strategies for some kind of underlying distress,” Dr. Jonathan Robison, a health educator, observes.  Incentive programs not only ignore those problems but may produce “a cycle of repeated failure.”

Better answers:  First, address people’s motives and deeper concerns rather than just trying to change their behavior. Second, help people to get some control over their lives.  Finally, build on their relationships with others to promote change. Couples and friends tend to lose weight together more effectively than do individuals.

Health can be a tough sell.  But it’s clearly something that incentives can’t buy.

For more information about the studies mentioned in this article, click here.