Overview

This summary is based on the article "Public Programs Are Using Incentives to Promote Healthy Behavior" in the September/October 2007 issue of States in Action.

Summary: Wisconsin is incorporating incentives for healthy behaviors into BadgerCare Plus, an expansion of its SCHIP program, known as BadgerCare. By piloting and evaluating at least five "Healthy Living" demonstration projects, Wisconsin hopes to identify creative, evidence-based approaches under the Healthy Living portfolio that could potentially be rolled out across the state.

The Issue: Among states, there is growing interest in offering incentives to those enrolled in public health plans to promote healthy behaviors. A number of states are developing programs to motivate enrollees to curtail smoking, lose weight, and access timely child immunizations and prenatal care. By providing rewards for healthy behaviors, these states are trying to give members a greater stake in improving their health status, enhance prevention and health outcomes, and reduce program costs.

Focusing on behavioral change to improve health and control costs is a central concept of "patient engagement," which is being promoted by the U.S. Department of Health and Human Services. The premise is that the motivating power of financial rewards for practicing healthy behavior can make a significant impact on the efficiency and effectiveness of health care. Thus, many incentive programs focus on two major sources of morbidity and mortality—smoking and obesity. Using incentives to change unhealthy behaviors is also related to two other trends: value-driven purchasing, which involves providing consumers with information about health care quality and costs, and patient-centered care. Each of these movements encourages people to take a more active role in their care.

States are using a variety of incentives to encourage healthy behaviors, primarily among Medicaid populations but also in the State Children's Health Insurance Program (SCHIP) and state-funded programs. Incentives can take the form of reduced cost-sharing, or vouchers or coupons for health-related products such as over-the-counter medications, as in Florida. As in Michigan, the rewards can be clinical services such as dental care, which may not be part of the standard Medicaid benefit package. California's Medicaid program provides non-health-related incentives, such as movie tickets or gift certificates, to reward parents who keep up with scheduled well-child visits for their infants and adolescents. Some states, including Wisconsin (described below), are seeking to link their incentive programs with efforts to improve health literacy.

Target Audience: SCHIP enrollees

The Intervention: Wisconsin is incorporating incentives for healthy behaviors into BadgerCare Plus, an expansion of its SCHIP program, known as BadgerCare. The goal of the expansion is to extend coverage to all of the states' uninsured children and to thousands of uninsured adults. Implementation is scheduled to begin on January 1, 2008. Once BadgerCare Plus is fully implemented, state officials hope that it will significantly reduce the state's uninsured population (currently 272,000 individuals), bringing access to affordable coverage to 98 percent of all residents.

One unique feature of Wisconsin's strategy is its request of health plans to develop grant proposals for individual incentive programs, through the new "Healthy Living" component of BadgerCare Plus. By piloting and evaluating at least five demonstration projects, Wisconsin hopes to identify creative, evidence-based approaches under the Healthy Living portfolio that could potentially be rolled out across the state. The programs are anticipated to begin in April 2008. According to Donna Friedsam, health policy director at the University of Wisconsin Population Health Institute, "there are two goalposts here. The end goal of course is behavior change. We want to see appropriate body mass index among children, more children immunized on time and early prenatal care; and we want to see members stop smoking. . . . [but] until we understand what incentives can get people engaged in the programming, we will not achieve significant success with incentives for behavior change."

In addition to the individual incentive programs, the state has developed a voluntary member pledge. By signing the pledge, families will promise to practice healthy behaviors; in turn, health plans will promise to support members in these efforts, in part through the incentive programs. The state is currently conducting focus groups with approximately 100 current BadgerCare members to learn what types of incentives might be effective, how they should be structured, and, perhaps even more important, what it would take to get people to participate in voluntary programs. The state envisions that health plans whose incentive strategies are chosen through the request-for-proposal process will work closely with providers and/or outreach workers to review the pledge with members, and to incorporate it into their overall strategy to improve patient health.

Finally, Wisconsin is developing a health literacy campaign to educate public plan members on how to ask providers appropriate questions to guide their health care treatment. It plans to use AskMe3 materials, developed by the Partnership for Clear Health Communication, which focus on three questions to facilitate discussion between patients and providers: "What is my main problem?," "What do I need to do?," and "Why is it important for me to do this?" The state is also considering working with providers in using the AskMe3 materials and, as with the member pledge, will ask health plans to incorporate the materials into their incentive program strategies.

According to both Friedsam and Linda McCart of the Wisconsin Department of Health and Family Services, medical directors of some participating health plans have already expressed interest in the use of incentives and the health literacy campaign.