The Effects of Financial Incentives on Intrinsic Motivation for Health Behaviors

Objective: To assess whether financial incentives for health behaviors crowd out individuals’ intrinsic motivation to engage in those behaviors. The use of financial incentives to promote changes in health behaviors is widespread among payers and employers, however there are concerns that if incentives crowd out intrinsic motivation, behavior would fall below even pre-incentive levels following the removal of incentives, hindering any long-run impact of incentives on behavior change. Further, consumers’ health-related decisions are likely impacted by the interaction between incentives and motivation. Few studies have assessed the impact of financial incentives on patients’ intrinsic motivation for health behaviors using direct measures of motivation. We examined this question in the context of five randomized controlled trials of financial incentives for health behavior change. We investigated whether effects varied by incentive type or behavior and assessed whether baseline or changes in motivation were associated with performance in behavior change programs.

Setting: We used the Treatment Self-Regulation Questionnaire to measure intrinsic motivation at baseline and at least once following the incentive intervention period in randomized controlled trials of financial incentives for weight loss (two studies), home health monitoring, walking among older adults, and adherence to use of a Positive Airways Pressure device for sleep apnea. In addition to varying health behaviors, these trials utilized different forms of incentives, including conditional payments, regret lotteries, and deposit contracts.

Methods: Multivariate regressions with participant-level data and random effects were used to assess the relationships between baseline and change in intrinsic motivation and performance in each study, measured as achieving study goals. Similar analyses were used to examine the effect of incentive eligibility and receipt on changes in intrinsic motivation to test for crowding out.

Sample: 561 participants in five randomized controlled trials of financial incentives for health behavior change.

Results: First, we found that an increase in intrinsic motivation during the intervention was associated with increased odds of success in the program, defined as achieving program goals such as a pre-determined weight loss target. Second, we found no evidence of crowding out of intrinsic motivation by incentives; that is, there was no significant association between incentive eligibility or receipt and the odds of a decrease in intrinsic motivation pre- versus post-incentives. The lack of evidence of crowding out was consistent across all five studies. (Further sub-group analyses to examine heterogeneity in our results as well as sensitivity checks are forthcoming.)

Conclusions: Financial incentives did not crowd out intrinsic motivation across a range of health behaviors and incentive designs. Improving our understanding in this area is critical in order to understand consumer decision-making in the context of health behaviors as well as to design the most effective incentives, understand in what settings they are most likely to work, and improve the potential for long-run behavior change.