I'm paying my patients cash to quit smoking
- on October 15, 2012
That is to say, next week I am starting a prize-linked smoking cessation program for my medical practice. Like most family docs, I am constantly reminding ‘smokers’ about the risks of tobacco and my ability to help them quit when ready. And like most physicians I probably have a false belief that pestering “enough” will spur action. As an unofficial student of economics and official student of public health (MPH), I should know better.
I have helped many patients stop smoking in my young career. However, I’m not really confident that my constant chirping is effective in initiating a cessation attempt that wouldn’t have occurred otherwise. Society is now fully aware of the harms of smoking (because of jerks like me) and are somewhat familiar with possible medical aids for quitting.
Provider-based “payment for performance” programs are already underway, but paying doctors more for “better” outcomes hasn’t proven very successful in most areas of medicine. Some have suggested it makes more sense to pay patients themselves, not doctors, for improved “performance” - often called “payment for performance for patients” (P4P4P)
Dr. Kevin Volpp and others have called for more pilot programs to evaluate the effectiveness of P4P4P. With a system financially stretched as-is, the next question is, “who pays?” Employers interested in “wellness” (and health care costs) have been the most active promoters of such programs. Some employers have already began to offer “prizes” of ‘paying less’ for health insurance premiums if certain wellness goals are met (seems more like poking the carrot in your eye), but not many have given cash rewards for behavior change.
Potential moral hazards for P4P4P do exist and were discussed in a 2010 NY Times piece. Concerns of coercion, bias and liberty are all legitimate when such programs are administered by large, powerful parties. However, I believe a voluntary, doctor-led program should be less objectionable and possibly more effective.
After listening to a Freakonomics podcast about the novel concept of “prize-linked savings accounts”, I was inspired to implement a prize-linked health promotion program in my new Direct Primary Care practice. I want to create a win-win health program for my patients, much like a prized-link savings account participants. So, I decided to start paying my patients cash to quit smoking - calling the program “Cash for Quitters”.
Starting next week I am going to offer any of my “daily-smoker” patients a chance to win a crisp $100 bill if they can 100% refrain from using tobacco products for a period of 6 months - “Cash for Quitters”. During their initial counseling visit, I am having each participant sign a “Zero Tobacco contract” approximately 1 month before the “quit date.” In addition to providing personal cessation counseling and pharmaceutical support, I am enrolling each patient in our state program KanQuit. At 3 and 6 months post “quit date” the patient will return to sign a ‘zero tobacco’ pledge and submit a urine sample for tobacco testing. If all requirements are met, each patient will be entered into a drawing next fall for the prize. I will likely repeat the contest in the future with a bigger prize as my practice grows.
With all of the self-evident benefits of smoking cessation, is it rational for the potential of $100 to influence a person to quit smoking? Probably not, but it doesn’t have to be rational to work. Furthermore, my constant chirping is getting old (even to me) and I’m going to put my money where my mouth is. Wasn’t it Adam Smith that said, “It’s all about the Benjamins, baby?”
W. Ryan Neuhofel, DO, MPH (Dr. Neu) is the physician and owner of NeuCare Family Medicine; a Direct Primary Care practice. He is a board-certified Family Physician (American Board of Family Medicine) and Fellow-candidate in Wilderness Medicine.
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