Over a decade ago, as a primary care physician with a Ph.D. in economics, Kevin Volpp, MD, PhD, director of the Center for Health Incentives and Behavioral Economics (CHIBE) in the Perelman School of Medicine at the University of Pennsylvania, noticed an interesting phenomenon in health care: across the board — from insurers, to providers, to patients — it had become normalized to spend great sums on health care services when a patient gets sick, but relatively little on keeping healthy patients healthy. For instance, there is a willingness to spare no expense when treating a heart attack or lung cancer, but less is invested on behaviors that increase risk for these conditions, like improving blood pressure or quitting smoking.
On a mission to understand this phenomenon and study ways to improve public health, Volpp founded CHIBE, which combines the clinical health expertise at Penn Medicine with the behavioral science and economic knowledge of faculty at Penn Medicine and Wharton to study how healthy behaviors can be rewarded and even encouraged.
Currently, as COVID-19 vaccines have become available to the general public and vaccination rates began to slow, there has been a boom in incentives for receiving the vaccine across the United States. States and businesses alike are rolling out rewards for people who provide proof of vaccination — from donuts, to beer, to guns, to Philadelphia’s own lottery for a chance to win up to $50,000.
Based on his research, including a recent article in The New England Journal of Medicine, in the following Q&A Volpp answers questions about health incentives for the COVID-19 vaccine and beyond.
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Kevin Volpp, MD, PhDHow does your research into health behaviors like weight loss and smoking cessation inform efforts to incentivize COVID-19 vaccination?
Typically, it is easier to motivate one-time behavior, like getting a vaccine, rather than behaviors over time, like weight loss, because that would require sustained engagement.
There are a number of factors that will work together to encourage the one-time behavior of getting a COVID-19 vaccine. First, the reward should be relatively immediate; the more time that passes between a behavior and the reward, the less likely a person is to associate the two.
Second, the program should be simple and easy to understand. A lot of rules or complicated registration will deter people from engaging with the promotion, and consequently, from getting the vaccine.
Third, there are a number of behavioral science findings that can further increase effectiveness of incentive programs. For example, losses loom larger than gains. That is, the disappointment of a dollar lost is about twice as powerful as the utility of a dollar won, which can motivate people to engage in behaviors that avoid losses. That is, someone who loses $100 by not doing something will typically be more motivated than the same person would be by winning $100.
In addition, incentive systems can be designed so that people will be notified if they won or if they would have won had they been vaccinated, leveraging a concept called ‘anticipated regret’, which people may feel if they miss out on potential monetary rewards for getting a vaccine because they had not been vaccinated.
People are also heavily influenced by their peers, so if it appears everyone around you is partaking in a behavior, you’re more likely to engage as well.
Finally, the incentive should be of a magnitude that matches what it’s enticing. Small rewards often don’t work and what is being offered should reflect both the economic value of the underlying activity and the barriers to changing that behavior.
There are a number of different incentives being offered by cities, states, and private businesses — from baseball game tickets to millions of dollars. Based on your research in motivating healthy behaviors, which of these will be most effective?
The data is still out on how effective each various incentive is, but any non-monetary incentive appeals to some people but not others. For instance, if I don’t drink beer or like baseball, those things will not motivate me.
Monetary incentives have universal appeal, and for that reason they typically will work better. The high stakes lotteries in places like Philadelphia and Ohio have gotten people’s attention since winning one of the big prizes ($50,000 or $1 million, respectively) have the chance to make a huge impact on someone’s life.
What’s more, people focus far more on the magnitude of the reward than the probability. These lotteries for COVID vaccination are offering monetary incentives of a magnitude unprecedented for a health behavior, and most people will only consider the benefit of winning that sum of money, and rarely consider how unlikely they are to do so.
Do you think continued incentives will be needed in the future for things like potential COVID-19 booster shots?
This is a concern of mine. With all of these incentives to get the vaccine now, we may be priming the pump for people to expect these rewards in the future.
My suggestion is to strategically implement social rewards. For instance, companies can appeal to peoples’ desire to return to normal, and allow large gatherings with proof of vaccination, as was done in a number of sports contexts such as live attendance at the NFL Draft or expanded seating being made available for New York Knicks and Brooklyn Nets games to those who are vaccinated. Travel to the European Union this summer is limited to Americans who are vaccinated. The incentive here is being able to partake in activities you’d otherwise miss out on without a vaccine.
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