Show them the money: Hashing out the ethics

Incentives increasingly impact health care

Cash incentives work well in certain situations, by increasing adherence and by cutting labor costs. They’re also very controversial. Even some proponents of cash incentives fear they may prove so tempting to needy patients that they function as a form of coercion, causing patients to make decisions they wouldn’t otherwise choose.

To opponents, the arguments against cash incentives are equally compelling. "We don’t believe in handing out money to everybody," says Carol Pozsick, RN, MPH, who is the TB controller for South Carolina. "Cash is sometimes used for things that are not good for the patients’ health — like drugs, alcohol, or [prostitutes]."

That’s true, says Lee Reichman, MD, MPH, executive director of the National Tuberculosis Center of the New Jersey Medical School in Newark.

But, he adds, so what? "We have no business making value judgments about what our patients do with the money," he says. "I know damn well what they do with the money, and I don’t care. My job is to eliminate TB, and if the best way to do that is to use cash incentives, then I’ll do it."

Besides, adds Reichman, patients given food or food coupons instead of cash routinely sell such commodities for cash. "Any resourceful drug user is going to turn a five-dollar McDonald’s coupon into cash," says Jennifer Lorvick, TB project director of Urban Health Studies at the University of California, San Francisco (UCSF). "We’re just making it a higher threshold. If you’re going to use an incentive, make it a good one, not a crummy one. That way, you motivate a person to do what you want them to do."

Like it or not, the world is already filled with various kinds of monetary incentives and disincentives, and many of them are beginning to filter into the health care system, adds Jacqueline Tulsky, MD, assistant clinical professor of medicine at UCSF.

"We take it for granted that people get paid salaries to do their jobs," says Tulsky. "They’re also charged higher rates for insurance if they smoke; they’re fined if they run a red light." Some proponents of cash incentives compare the payments to a salary. "I tell people, ‘It’s your job to get through this medication and to not develop TB and give it to other people,"’ says Tulsky.

Still, paying people cash to take medicine sends the wrong message, Pozsick believes. "I feel the heart of incentives is, literally, the heart," she says. "It’s a one-to-one relationship; it’s picking something that’s special to that one person."

She tells the story of a creative outreach worker who devised a coupon book for a mother whose daughter wanted a pretty dress for the prom. By the time spring had rolled around, the coupon book was filled out, the course of medication was completed, and the mother was able to buy her child the dress she wanted.

That’s fine in some cases, say Lorvick. But for people who aren’t moved by coupon books for prom dresses, health care workers should set aside their scruples and use what works. "It’s hard for regular middle-class people to get through a 10-day course of antibiotic therapy," Lorvick says. "Why shouldn’t it be hard for someone who’s a drug user to get through six months of TB therapy?"