Abstract
Several states have implemented Healthy Behavior Incentive Programs (HBIPs) in Medicaid through Section 1115 demonstration waivers. These programs use financial incentives to encourage positive behavior changes, such as greater use of preventive services, smoking cessation, and weight loss. To test for an association between the introduction of HBIPs and the rates of smoking cessation, weight loss, and annual preventive health visits in states that have adopted behavior-specific programs compared with states that have not. A cohort study using a difference-in-differences analysis of the 2011-2016 Behavioral Risk Factor Surveillance Survey Interview Results data, adjusting for demographic conditions, state unemployment rates, state Medicaid expansion, national secular trends, and time invariant state-specific factors, was conducted. Two sets of participants were considered: adults aged 18 to 64 years who had a reported annual household income of less than $25 000 (n = 442 089) or adults aged 18 to 64 years who had completed high school education or less (n = 676 883). Changes in health behavior outcomes in 4 states (Florida, Indiana, Iowa, and Michigan) that implemented behavior-specific HBIPs targeting smoking, obesity, and annual health checkups through a Section 1115 waiver, against changes in control states, including Washington, DC, that did not introduce an HBIP (n = 44). Rate of smoking, obesity, and attendance at annual preventive health visits. Of Behavioral Risk Factor Surveillance Service respondents used for the less than $25 000 annual household income cohort (n = 442 089), the mean (SD) age was 43.1 (0.8) years, and the mean (SD) percentage of women was 58.4% (2.5%). For the cohort of high school education or less (n = 676 883) population, the mean (SD) age was 41.6 (1.1) years, and the mean (SD) percentage of women was 46.6% (0.9%). During a 2-year period after implementation, there were no improvements in smoking and obesity in individuals with a household income of less than $25 000 (2.49 percentage points, 95% CI, 1.75-3.23 percentage points; P < .001 and -1.94 percentage points, 95% CI, -4.42 to 0.55 percentage points; P = .12, respectively) as well as in the population holding a high school education or less (1.74 percentage points, 95% CI, 0.64-2.85 percentage points; P = .003 and -0.73 percentage points, 95% CI, -1.84 to 0.38 percentage points; P = .19). An association was noted between an increase in preventive health visit rates among states adopting behavior-specific HBIPs relative to control states in the less than $25 000 household income population (3.89 percentage points, 95% CI, 2.64-5.14 percentage points; P < .001). However, these associations were substantively small and not robust across the high school education or less population (1.8 percentage points, 95% CI, -0.12 to 3.71 percentage points; P = .07). Early postimplementation assessment may indicate that HBIPs were not associated with substantive improvements in incentivized healthy behaviors among populations likely to be Medicaid beneficiaries. The value, format, and timing of the incentive, complexity in delivery, and lack of awareness of incentives among target beneficiaries and clinicians may limit the usefulness of programs even over a longer follow-up period.
Highlights
Health risk behaviors, such as smoking, consuming a poor diet, engaging in limited physical activity, and not participating in health screening, can increase the risk of avoidable premature morbidity and mortality.[1,2] These behaviors have proved difficult to modify.[3,4] Recent research from the field of behavioral economics suggests that financial incentives may be effective in achieving smoking cessation,[5,6] weight loss,[7] increased exercise,[8,9,10] and medication adherence.[11]
Early postimplementation assessment may indicate that Healthy Behavior Incentive Program (HBIP) were not associated with substantive improvements in incentivized healthy behaviors among populations likely to be Medicaid beneficiaries
Study Design We used a difference-in-differences research design to compare changes in the rates of 3 predetermined healthy behavior outcomes—cigarette smoking, obesity, and annual health checkups—before and after the implementation of HBIPs, which addressed these behaviors through Section 1115 waivers, against the same changes in states that did not implement an HBIP waiver
Summary
Health risk behaviors, such as smoking, consuming a poor diet, engaging in limited physical activity, and not participating in health screening, can increase the risk of avoidable premature morbidity and mortality.[1,2] These behaviors have proved difficult to modify.[3,4] Recent research from the field of behavioral economics suggests that financial incentives may be effective in achieving smoking cessation,[5,6] weight loss,[7] increased exercise,[8,9,10] and medication adherence.[11]. Seven states (Arizona, Florida, Iowa, Indiana, Michigan, New Mexico, and Kentucky) have received a waiver to enact Healthy Behavior Incentive Programs (HBIPs). Of these states, Florida, Michigan, Iowa, and New Mexico have had HBIPs in place for more than 4 years, while Indiana’s has been in place for more than 3 years and Arizona’s HBIPs have been in place for more than 2 years. Kentucky’s HBIP was approved in early 2018 but suspended by a court ruling and currently remains under review; Wisconsin currently holds a pending application.[13,14] Examples of proposed or enacted incentives across these programs include reductions in or waivers of premiums, rollover of saved funds in health accounts, or gift cards.[15] the effects of these HBIPs on targeted health behaviors in these programs is not known
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