ACP explores ethical issues for use of incentives to promote personal responsibility for health

The American College of Physicians (ACP) today released a new position paper that provides ethical guidance for using incentives to promote personal responsibility for health.

In "Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond (http://www.acponline.org/running_practice/ethics/issues/policy/personal_incentives.pdf)," ACP stresses that innovative programs designed to motivate behavior change should be part of a comprehensive strategy for well-being and prevention using evidence-based practice to develop nondiscriminatory programs that do not punish patients for unhealthy behaviors.

"ACP's paper is timely because the Patient Protection and Affordable Care Act includes funding for state grants to develop initiatives that provide incentives to Medicaid beneficiaries for the prevention of chronic diseases," said ACP President J. Fred Ralston Jr., MD, FACP. "The PPACA specifies that incentives shall not affect eligibility for or amount of Medicaid or other benefits, which is consistent with our position of supporting positive incentives under limited circumstances."

ACP used the West Virginia Medicaid program -- one of the early, controversial programs to use incentives -- to highlight its positions. Programs that support the patient's role in promoting positive health outcomes, ACP emphasizes in the paper, should be evidence-based and should focus on increasing access to strategies for prevention and treatment of disease; support patient autonomy and participation in decision making; consider variables influencing comprehension and learning; and respect cultural, religious, and socioeconomic conditions. ACP opposes the use of negative incentives that penalize patients for failing to meet stated goals by withholding or reducing benefits, or by increasing premiums for health insurance.

"Incentive programs should not discriminate against a class or category of people," said Virginia Hood, MBBS, MPH, FACP, a co-author of the paper for ACP's Ethics, Professionalism and Human Rights Committee. "Age, gender, race, ethnicity, and socioeconomic status should be carefully considered in designing, implementing, and interpreting results of social and behavioral interventions."

In addition, according to the position paper, incentive programs to promote behavior change must:

• be equitable and not penalize individuals by withholding benefits.
  
• support a patient's right to refuse treatment without punitive consequences.
  
• be transparent and provide a clear explanation of the benefits and operational details.
  
• support the patient-physician relationship and the physician's ethical and professional obligations to care for patients.
  
• be designed to allocate benefits equitably.
  
• facilitate patient-centered care.