Prevention 2040: A social shift if healthcare providers are still rewarded for treating patients?

Value of prevention

It is a popular opinion to be a proponent of “prevention”, even though it is often for the wrong reasons. In contrast to popular belief, prevention does not necessarily reduce lifetime health care costs. Still, is has the potential to be a cost-effective tool for improving population health and worker productivity. Moreover, at the individual level people often aspire to live healthier lives, so encouraging healthy lifestyles may also increase individual wellbeing, at least for some.

Combining skills with stakes

In Smarter Choices for Better Health (SCBH), “Prevention” is one of the core themes. Over the past 4 years, we have brought together a group of (behavioral) economists, health psychologists, clinicians, and public health researchers to improve understanding of preventive behaviors at the individual level. For example, we are currently designing an e-health intervention that combines psychological skills (e.g., action planning) with economic stakes (committing monetary amounts to achieving that action) to help women at high-risk for developing cardiovascular disease build their physical activity routines.

Behavior change is hard

However, behavior change is hard. 53 distinct interventions designed by an all-star team of behavioral scientists united in the Behavior Change for Good initiative only moderately improved physical activity after the 4-week intervention stopped. Therefore, in recent years, there is more attention for the social context in which behavior is grounded. The obesogenic environment (e.g., availability of fast-food) is contributing to soaring levels of obesity, and more generally it is recognized that cultural norms and stress resulting from poverty may drift people away from healthy behavior. A successful and sustainable intervention to encourage prevention and healthy behaviors therefore must combine incentives and nudges at the individual level with a redesign of the choice architecture of the individual’s environment.

A fee-for-non-service?

It is my conviction though that even this combination of individual and community level is not enough to achieve the ambitious goals of the “Prevention-agreement”. What we additionally need is a change at the system-level in terms of the financing of health care. How can we expect a societal shift from cure to prevention if the incentives for health care providers are still based upon a “fee-for-service” or “DRG” system that rewards treating patients? Shouldn’t health care providers rather be rewarded for maintaining a healthy population that does not require treatment, i.e. a “fee-for-non-service model?”

Align incentives towards 2040

It is my ambition for the upcoming Smarter Choices for Better Health 2.0 initiative to align the incentives for prevention at individual, community and system level. Erasmus University and Erasmus MC jointly have the expertise to co-design the “Prevention 2040” health system that provides the right incentives at the three levels. Elements could include (i) skills, nudges and incentives to encourage healthy behavior at the individual level; (ii) clever choice architecture to make healthier options attractive; (iii) “value-based prevention” (e.g., no cost-sharing for high-value preventive care); and (iv) a fee-for-non-service model to make it attractive for hospitals and other health care providers to prevent patients from entering rather than curing them upon entrance. Who’s joining?

About the author 

Hans van Kippersluis is a Professor of Applied Economics at Erasmus School of Economics. His focus is on inequalities in health and human capital, and how people can be encouraged to invest in their health and education.