Bonuses as incentives and rewards for health responsibility: a good thing?

Journal of Medicine and Philosophy, 33: 198– 220, 2008 doi:10.1093/jmp/jhn007

Bonuses as Incentives and Rewards for Health Responsibility: A Good Thing?

HARALD SCHMIDTLondon School of Economics and Political Science, London, UK and Nuffield Council on

Bioethics, London, UK

Bonuses, as incentives or rewards for health-related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health-care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health-care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices.

Keywords: bonus, contractualism, equity, german health reform, health promotion, incentive, prevention, responsibility, solidarity

I. INTRODUCTION

A “bonus” is, broadly, a good thing. In policy and practice, bonuses feature in arrangements such as linking professional performance to payments over and above a certain base rate, awarding frequent-flier air miles, or offering

Address correspondence to: Harald Schmidt, LSE Health, LSE, Houghton Street, London, UK, WC2A 2AE. E-mail: [email protected].

© The Author 2008. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: [email protected]

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reward cards for supermarket shoppers. In Germany, sickness funds providing statutory health insurance have offered a range of bonuses, for a range of health-related behaviors, since 2004 (Braun et al., 2006; Knaack, 2008).

The available bonus schemes have different goals, and there are several reasons behind their introduction. They are focused centrally, first, around the moral concept of personal responsibility for health. Closely linked to the concept of solidarity, responsibility plays a prominent role in the German health- care system, and bonuses are viewed as a way of incentivizing and rewarding responsible behavior. Second, as for many other publicly funded health-care systems, the economic strain imposed by “lifestyle diseases” such as obesity and other chronic conditions are of increasing concern, and, in a more instru- mental sense, bonuses are viewed as one (of several) practical means of improving active participation in primary and secondary prevention and reducing cost. Third, the opening of the German insurance market to private providers in 1994 has resulted in increased adoption of market mechanisms by public providers, with the hope of thereby increasing overall efficiency. A range of measures has been introduced to improve competition between sickness funds, and practically all the major insurers offer bonus systems, fully aware of their marketing potential in terms of attracting and retaining customers.

Ideally, bonus policies help to achieve all the above goals to the benefit of everyone, disadvantaging no one. However, it is not clear that this is always the case. Moreover, I will argue, it is also not straightforward to identify which (set) of the goals exactly is sought to be achieved by particular bonus programs, and whether they can always be viewed as compatible with the ethical values underlying public health-care systems in general and the German system in particular.

Below, I will analyze key features of recent German bonus systems. In the first section I will provide a brief background to the role of personal responsibility in German health-care law. The second section sets out a framework for analysis of health responsibilities. In the last section, this framework is used to evaluate particular legal and policy provisions that relate to bonus systems aimed at encouraging different notions of health responsibility.

It should be clarified at this stage that in using the term bonus nothing is implied about the acceptability of the method or about the precise method of its functioning. Bonuses may work as an incentive in the sense that they are the sole reason why a person adopts a certain behavior, raising possible issues about undue inducements. Or they may merely “nudge” people to do something they intended to do but did not for lack of general motivation. Or they may constitute a spare wheel, a redundant “extra,” as the fact that a bonus was available actually had no effect on the behavior that entitled people to a bonus. In principle, the means for bonus payments may be raised through cross-financing (by other insurance holders) or perhaps by sharing a proportion of savings that are made because some kind of treatment is not required as a consequence of behavior change.

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The concept of health responsibilities, in the following, is understood as referring to obligations that, for a range of reasons, healthy people, patients, and the reconvalescent may be said to have toward themselves (in the broad- est sense: “lead a healthy life”), toward others (“promote and do not damage the health of others”), or toward a health-care system (“contribute to its equitable and efficient operation” [Resnik, 2005, Schmidt, 2007b, English, 2005]).

II. SOLIDARITY AND HEALTH RESPONSIBILITY— THE GENERAL LEGAL CONTEXT

Book V of the German Social Security Code (Sozialgesetzbuch—SGB) regulates the provision of statutory health care. Its norms are binding for all sickness funds providing care for approximately 90% of the German population (the remainder being covered by private insurance). Article 1 of SGB V has overarching function and is entitled “Solidarity and personal responsibility.” A characterization of both concepts is provided in the wording of Article 1 that reads:

In the spirit of a mutually supportive community [Solidargemeinschaft] the task of the statutory health insurance is to maintain, restore or improve health of the insured. The insured have co-responsibility for their health; through a health- conscious way of living, taking part in appropriately timed preventative measures [and] playing an active role in treatment and rehabilitation, they should contribute to avoiding illness and disability, and overcoming the respective consequences. The statutory sickness funds are to assist the insured persons through the provision of information, advice and services, and should encourage a health-conscious way of living [my translation].

The principal characterization of solidarity and personal responsibility is that the community as a collective, and people individually, are co-“producers” of health. The notion of co-responsibility has two important facets in this respect. First, it states that the “mutually supportive community” has a certain degree of responsibility for the health of each individual. In this sense, individuals are entitled to claims against the community for assistance. Second, it also implies that the community has certain claims against individuals. Leaving prudential benefits aside, the appeal to staying healthy has the aim of containing overall expenditure and opportunity costs. For all care needs to be financed by the solidaristic community, and limiting ones demands on the healthcare system reduces expenditure. Using services unnecessarily may also deprive another person in need of resources or medical attention, exacerbating resource allocation dilemmas.

Article 2 SGB V on “necessity, cost-effectiveness, and personal responsibility” is unequivocal in stressing people’s obligations in this respect:

Services … are to be provided by the sickness funds with due respect to cost effectiveness [Wirtschaftlichkeitsgebot] … and insofar as the need for services is not attributable to the personal responsibility of the insured person. […] Sickness funds,


service providers and insured persons must seek to ensure the clinical and cost- effectiveness of services, which are only to be used insofar as necessary [emphasis added, my translation].

Article 2 raises the question of what exactly, in practice, the respective scope and limitation of solidaristic and personal responsibility should be. Is there a “worst-case” scenario in which solidaristic coverage would be refused?

Article 52 SGB V sets out conditions under which statutory sickness funds may limit funding for services, and the most recent health-care reforms of 2007 included a noteworthy specification in this respect. In its pre-2007 version, Article 52 stated that insurers may demand a reasonable contribution to the costs of treatment, if a person’s need for health care is the result of engag- ing in a criminal activity. Under the 2007 amendments, this principle has been extended to state that insurers may ask for equivalent contributions where people request treatment for complications arising from “cosmetic surgery, tattoos … piercings,” or another “non-medically indicated” measure.

Solidarity and personal responsibility in the old version of Article 52 were interpreted in such a way that whoever harms the solidaristic community has lost the claim to having health care needs met at their exclusive expense. In such cases, financing health care can become a matter of personal responsibility. However, this responsibility extends to the costs only: for solidarity still clearly requires the criminal person to be treated by the health-care services. The new extension regarding, not criminal action, but nonmedically indicated measures, is far more problematic.

In the following, I will not focus on an analysis of these extreme cases. However, their review can help identify the principal questions we need to ask when we try to decide about the acceptability of appeals to responsibility. I suggest that to evaluate such provisions, as well as, in fact, any health responsibility–related policy, including bonus programes, the most helpful approach is to carry out a number of “tests” that concern the impact of the respective policy on key normative and structural values and components integral to a public health-care system. These tests concern solidarity; equality and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence.

III. A FRAMEWORK FOR EVALUATING HEALTH RESPONSIBILITIES

This proposal clearly raises at least two questions: First, why the talk about tests and not ethical principles or a particular branch of moral theory? Sec- ond, why these tests, and what exactly do they involve?

At one level, deciding about an appropriate concept of health responsibility might simply be a matter of choosing the right set of principles or theoreti- cal framework. For example, Hans Martin Sass has called for a triad of “responsibility, solidarity, and subsidiarity,” viewing in particular the principle

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of solidarity as “deeply rooted in European culture and supported by secular … and Christian ethical positions” (Sass, 1995, 587). Within political philosophy, responsibility features prominently in luck egalitarianism,1 but also in communitarian2 and libertarian,3 accounts. And the responsibility debate is of course also closely aligned with particular political positions. The left generally argues that the focus on the individual is misguided and that it is the en- vironment and general living conditions that require change for people to be healthy. The right focuses more strongly on individual behavior and notions of desert, coupling entitlements to health and other social care more closely to responsibilities (Schmidt, 2007a).

So in one sense, the question of health responsibilities might simply be a matter of choosing “the right” normative framework. However, there are two principal problems with this approach. First, in value pluralistic societies, agreement about what constitutes the right framework remains generally elusive. Second, even if we suppose that we are able to find a country in which all residents (or just citizens) can agree on a single monolithic theory or accept a set of principles such as Sass’ triad, such value systems are typically of a very general nature and may not tell us more geometrico how to decide particular cases, or, in the present context, judge concrete policies. The approach proposed here, focusing on addressing questions around health responsibility with a number of tests, by contrast, has several advantages, and can be used in three different ways.

First, the tests specify clearly the areas in which justification is required. In one sense, they might be understood to be complementary to the aforementioned normative frameworks, within which subsequent justification in each particular area may be provided. On this view, the tests may be seen as a necessary, although not sufficient, condition of relating abstract theory to specific policy proposals and making sense of the meaning of health responsibility.

Alternatively, the “fact of pluralism,” characterizing modern liberal societies, might be taken more seriously, and the focus on particular normative frameworks for justification may be relegated to the background. Accord- ingly, setting out a range of tests can be useful, if not constitutive, in a more policy-orientated approach that focuses on “accountability for reasonableness,” as set out by Norman Daniels and James Sabin (Daniels, 2000). Here, the idea that a universally accepted notion of personal responsibility can be realized in pluralistic societies is abandoned, but the argument might be made that as long as policies fulfill four conditions (relating to publicity, relevance, revision and appeals, and regulation) and as long as explicit justification in each of the areas specified by the tests is provided, reasonable policy has been secured (Schmidt, forthcoming).

Lastly, the fact of pluralism and the normative value of justification may be acknowledged by using the tests within a contractualist framework, as presented, for example, by contemporary proponents such as Thomas Scanlon. Although, for space and other reasons, I shall not pursue this general project


here, I contend that this is in fact the most promising strategy, not least because of Scanlon’s discussion around responsibility. I will return to his useful distinction between responsibility as attributability and substantive responsibility below, and I will assume in the following that it makes sense to use the tests sketched out here in a project that focuses on identifying those principles or policies that, provided people have certain choices, “no-one could reasonably reject” (Scanlon, 1998, 153). The corollary is that such norms have particular robustness and in fact special moral value. However, even if the reader is not inclined to make this leap at this stage, it will become clear that the proposed framework is well suited to interrogate the German policy on health-care bonuses as set out in SGB V and provide helpful illumination of significant ethical tensions.The seven tests proposed here are not intended as an exhaustive list. However, they are informed by an analysis of the kinds of issues raised by legal and policy provisions found in major patient charters and similar docu- ments4 and by the range of arguments typically set forth by proponents and opponents of health responsibility.5

Solidarity Test

Health as a good is special in at least two ways: first, in a very obvious sense, good health matters in our lives in experiential, if not existential terms. Sec- ond, health has a clear impact on one’s civic and economic livelihood and the options one can make use of in a society based on fair equality of opportunity (Daniels, 2007). On an individual basis, regaining health in the case of sickness can be extremely costly, if not impossible to afford. Admit- tedly, countries that have made social health insurance mandatory have taken away a degree of liberty in relation to whether or not people should protect themselves against the consequences of poor health. But nonetheless, it is plausible to describe those brought together in social health insurance systems as being in a solidaristic relationship with others, which has the aim of providing mutual protection against the negative implication of diseases.

In the German law, solidarity is, as discussed briefly above, linked closely to the concept of personal responsibility. Further, solidarity is addressed in relation to the financing of health care. Employers and employees split contributions, each paying 6%–8% of the employee’s gross salary. Contributions are not taxed and are capped at an annual gross salary of currently €46,350. There is no individual or sex-specific risk assessment, and contributions and expenditures are generally pooled. Therefore, solidarity means, first, that those who are able to work, especially healthy and young people, support the less healthy, unem- ployed, and older (or retired) individuals as they contribute more and generally use less resources. Second, due to means-tested contributions, the more well- off support the less well-off. Third, those without families support those with

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dependents, as partners and children are insured at no extra cost through the main insurance contributor (the person working and paying insurance contributions).

In addition to the more strategic characterization of solidarity above, where, under a form of fair reciprocity, equals join up for mutual benefit, this sketch of the German financing system also reveals a different notion of solidarity: inbuilt in its focus on extending coverage to people in especially vulnerable situations is a notion of solidarity as “giving-without-expectation- of-return.” The general concept of solidarity is highly complex. In addition to the two notions introduced here, recent work examining its motivation, function, and role in different European health-care systems has analyzed it among other things, as attitudes of individuals or descriptions of communal arrangements, and has explored notions of fellowship, compassion, charity, altruism, universal or group-specific brotherhood, friendship, interest coali- tions, civic duties, or mutual recognition and interdependency of individuals (Houtepen and Meulen, 2000a).

Although there are hence a range of different candidates that might ex- plain why solidarity should matter, it is clear that a functional baseline description of solidarity in public health-care systems would be focused around the notion of achieving collectively a degree of security that could not generally be achieved individually. In this sense, solidarity has also been charac- terized as “the ‘beating heart’ of a social health insurance approach” (Saltman, 2004, 29).6 It is equally clear, then, that any evaluation of appeals to health responsibilities, whether in the form of bonus systems or policies that have a more negative character, needs to consider whether they are likely to en- hance this central concept or will be to its detriment.

Equity and Equality Test

Broadly speaking, inequalities relate to the uneven distribution of goods (or access to them), and such distributions are inequitable when they are unfair or unjust. In one sense, one could assume that assessing a policy in terms of its impact on solidarity is the same as assessing it in terms of its impact on equality and equity. However, this is not necessarily the case, as there can be arrangements that satisfy a particular concept of solidarity, al-though they may not treat everyone equally and/or equitably. For example, although a system might be described as solidaristic in view of the mechanisms of financing and access to health services, other organizational arrangements or societal factors may mean that some groups of people benefit more than others. Given that the reduction of inequalities in health and social status through largely prioritarian strategies is an explicit goal of all liberal European states, it is therefore useful to assess whether particular responsibilities are likely to contribute to reducing inequalities or not.


Intrusiveness Test

Promoting personal responsibility is often seen as synonymous with imposing highly intrusive and paternalistic measures. However, this is far from necessary, and the means available include mere provision of information or nondirective education, targeted and directive education and persuasion; the use of financial and other incentives and disincentives, possibly targeted at different populations (taxes, different levels of insurance contribution or co- payments, bonuses, etc.); restricting access to particular interventions; and ultimately infringing civil liberties (such as mandatory isolation of people with highly infectious diseases who refuse to accept the responsibility not to harm others). (Nuffield Council on Bioethics, 2007)

Minimizing intrusion is not only of relevance in terms of respect for au- tonomy but also with regard to the acceptability and sustainability of a program seeking to promote responsibility. The intrusiveness test therefore concerns the extent of interference and in a wider assessment whether a particular measure is likely to be the least intrusive, but most effective of a set of available options.

Attributability and Opportunities of Choice Test

One of the most controversial issues in the debate about health responsibilities concerns the question of how to consider, in praising or blaming, or making decisions about access to health care, the extent to which people’s behavior contributed to a good or bad health outcome. Controversy sur- rounds, in particular, the discussion around negative health outcomes and their association with blame and reduced access to health care.

For some, the question of holding people responsible or imposing sanctions is the same as assessing the extent to which an action is attributable, as, for example, also suggested verbatim in the above quote from Article 2 SGB V. However, attributability can admit of degrees, and the question might then turn on what degree or threshold of attributability should be sufficient. This is particularly relevant in considering responsibility in the health-care context. For, clearly, disease development is affected by a highly complex range of factors that include genetic predispositions, biological processes, and environmental conditions, in addition to behavior. It would amount to a Kafkaesque situation to say someone has only themselves to blame for a health outcome and has lost all claims to assistance if the actual causal factors were in fact fully, or to a significant extent, outside of that person’s con- trol. One option, therefore, is to abandon any talk about apportioning responsibility for bad health outcomes.

Another is to analyze more closely the kinds of responsibilities involved. Scanlon distinguishes two principal types. Responsibility as attributability concerns our assessments relating to praise and blame and rests on whether a given action is attributable in the sense that the choices were guided by

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the attitudes of the person who is judged (Scanlon, 1998, 290). Hence, we might acknowledge that in the case of some people, their behavior played a certain causal role in contributing to a disease but not feel it appropriate to blame them for it. There may be others, however, where we might want to do so, provided their behavior was guided by their attitudes. And equally we might praise people in cases where their attitudes led to behavior that produced a good health state. However, adapting Scanlon’s model, none of these assessments determine what people are owed. Such obligations rest on substantive responsibility, which can be independent of the choices a person has made. On this view, what a person is owed is determined primarily, if not exclusively, by the opportunities a person had for making the right choices: “what matters is the value of the opportunity to choose that the person is presented with. If a person has been placed in a sufficiently good position, this can make it the case that he or she has no valid com- plaint about what results, whether or not it is produced by his or her active choice” (Scanlon, 1998, 258). In deciding what kind of opportunities need to be provided in this respect, Scanlon suggests that we should be guided by reasons “that people in general have reason to value,” as “the justifiability of a moral principle must rest on [generic reasons]” (Scanlon, 1998, 263, cf205) people have in a given situation and not on their particular values and attitudes.

For the evaluation of particular polices, it then follows that a close assessment is required of the kinds of opportunities that they create and how they relate to the general opportunities that people have in their lives. People’s claims against the solidaristic community may only be lessened if the policies have provided them with option sets that allow people motivated by generic reasons to prevent harm. In a positive sense, substantive responsibility may justify offering rewards for positive behavior. And independently of the question of substantive responsibility, the notion of attributive responsibility may still allow us to praise or blame people’s behavior, or to appeal to them to change their behavior where we judge they should behave differ- ently and it is in their power to do so. But the latter judgments are distinct from decisions about what people are owed.

Evidence and Rationale, Feasibility Test

As obvious from the brief discussion around Article 1 SGB, in view of possible opportunity costs, personal responsibility can be emphasized on the grounds of fairness toward others in the solidaristic community. Or it may be based on a more general appeal to efficient use of health-care resources. In any case, evidence is required that a particular policy and means used to enforce it will actually help realize the justificatory reasons. Being explicit about evidence and underlying rationales is crucial in justifying and securing support for particular health responsibility policies, and to avoid “legal moralism”


(Wikler, 1978, 316, 332), where particular behaviors are rewarded or penal- ized simply because those setting policy have a like or dislike for them. An assessment of the rationale may also help us to understand better the primary beneficiaries of particular polices, who may not always be individual people, or the solidaristic community, but perhaps (also) insurance providers or government departments receiving taxes.

In considering different policy options, an assessment is furthermore required of the administrative and general organizational effort necessary to set out health responsibilities, and, where deemed appropriate, to enforce them. It may be that although some types of responsibility can be clearly specified, and are reasonable, their enforcement would simply be dispropor- tionate in terms of cost or effort.

Affected Third Parties Test

The implementation of responsibilities set out in law or policy also needs to consider the effect on third parties. Doctors may (or may not) wish to appeal to patients’ responsibilities to change their behavior. However, depending on the type of responsibility, doctors may also be required to pass on information to sickness funds or similar agencies about whether or not people comply with particular obligations. This may affect the doctor-patient relationship, as it may give an unwelcome policing function to health-care professionals or may have a negative impact on people’s willingness to come into contact with health services. The implications of particular responsibilities for the various agents involved and the relationships between them, therefore, also require close scrutiny.

Coherence Test

Justice, in one meaning, demands treating similar cases similarly. Particular forms of health responsibility therefore need to be compared to other health responsibilities and to obligations in social policy more widely.

A comparison to other areas of social policy may furthermore be interesting since many of the hard questions in apportioning responsibility also arise in other contexts, such as criminal, tort, and liability law. For example, in the United Kingdom and Germany, contributory negligence (Eigenverschulden) commonly leads to reductions in personal injury claims brought by victims of traffic accidents who failed to wear a seat belt (if wearing the seatbelt would have prevented or significantly limited the harm caused). Of course, such comparisons do not mean that identical standards need to be implemented in the health context—there may be morally relevant differences. But ultimately, a coherent use of responsibility would be the ideal outcome, whether this means similar or distinct policies.

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IV. BONUS SYSTEMS IN GERMANY—ANALYSIS

The next section will illustrate the usefulness of the above tests in identifying different types of ethical “pulls” arising from a range of appeals to responsibility in the German health-care system. Some of the bonus programs discussed here have an obvious motivation of improving both health of the person concerned and the efficiency of the health-care system (such as bonuses for participation in primary prevention), whereas others are primarily cost driven (such as bonuses for no-claims behavior).

Description of Bonus Systems

General primary and secondary prevention

Since 2004, Article 65a SGB V permits providers of statutory health insurance to offer bonuses for those who take an active part in a range of primary and secondary prevention measures. One may qualify by taking part in age- related checkup programs (such as presymptomatic examinations for cardio- vascular diseases, diabetes, and kidney diseases) or in particular health maintenance activities that are supported by sickness funds. These may include attending dieting, smoking cessation, or yoga courses. Some sickness funds also accept active membership in a sports club as evidence of efforts to maintain one’s health.

Bonuses may take different forms. One type consists of awarding points of a nominal value for taking part in certain measures. Once a certain threshold of points has been reached, they can be redeemed for a range of items including sports equipment, health books, iPods, or vouchers for mu- sic downloads. Many providers also offer the option of redeeming the col- lected points for cash. For example, in the case of one of the biggest providers, the Techniker Krankenkasse, qualifying measures typically have a value between €5 and €30 (with an arithmetic mean of €10.48). A four- person family may redeem between €100 and €200 per year through such schemes. The Barmer Ersatzkasse allows members to reduce their insurance contributions. For example, a 45-year-old person living in the western parts of Germany, with no children, earning €2,500 gross per month can save 6.97% of monthly contributions (or €5.83) by demonstrating that indices such as body mass index (BMI), blood pressure, blood sugar, and choles- terol are in an acceptable range over a period of at least 1 year (Schmidt, 2007c).

Secondary prevention: cancer screening

The 2007 reforms introduced a particular incentive program for potential breast, cervical, and colon cancer patients. Previously, Article 62 SGB V determined that health-care co-payments for chronically ill patients suffering


from such and other chronic diseases were capped at a maximum of 1% of their gross annual income. From January 2008, this has been increased to 2%; however, people can reduce the co-payment threshold to 1% if, firstly, prior to becoming sick, they have attended (nondirective) counseling sessions on the advantages and disadvantages of screenings for each disease no later than 2 years from the qualifying age, and secondly, if in case of a later disease a doctor issues on an annual basis a certificate confirming that the patient has adhered to previously agreed treatment plans. Following some controversy it was agreed that non-compliance would be certified only in those cases where patients refused treatment (Gemeinsamer Bundesausschuss, 2007).7

Secondary prevention: dental care

Article 55 and 56 SGB V stipulate that providers of statutory health insurance must cover 50% of the costs for required dental replacements, with the other half falling to the insured person. Insurance providers must increase their contribution by 20% of their initial payment, if, over a period of 5 years, adults have taken part in annual checkup programs (and under 18 year olds in biannual ones). If there are no gaps over the past 10 years, this is increased to 30%. However, if there are gaps, the insured persons have to pay their full 50%.

Bonuses and personalized plans

Under the health reform 2007, implemented by the Gesetz zur Stärkung des Wettbewerbs in der gesetzlichen Krankenversicherung “Law to strengthen competition among statutory sickness funds”) Article 53 SGB V has been revised to require all sickness funds to provide five defined “personalized” plans (Wahltarife) which relate to the participation in special care programs (including particular schemes recommended by the sickness fund, schemes that focus on general practitioner (GP)-centered care, and using outpatient services from an agreed set of providers only). Since these programs are thought to reduce the burden of morbidity and costs for the insurers, contributions for those taking part in the schemes may be reduced, or lower co-payments for services may be offered, where such payments are required. In addition, insurers may offer plans that include “no-claim bonuses,” irrespectively of whether people also make use of one of the aforementioned programs. Bonuses of up to 20% of the annual insurance contributions may be awarded, capped, however, at €600 maximum (or €900, where several different bonus plans are combined). While “no-claim bonus” schemes differ in their precise conditions between providers, they generally revolve around limiting the use of prescription drugs and hospitalization (in the case of one major provider, no GP appointments for prescription drugs and no hospitalization over a year secures the maximum bonus) (Schmidt, 2007c).

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V. DISCUSSION

Evidence, Rationale, and Feasibility

The most general question in considering the evidence, rationale, and feasibility of bonus programs aimed at health promotion probably concerns the question of whether such measures can in fact help contain overall health- care expenditure (Cohen et al. 2008, Schauffler 2000).

Clearly, looking after oneself can improve health, reduce health-care needs, and extend life expectancy. For example, according to the recent large-scale european prospective investigation into cancer and nutrition (EPIC)-Norfolk Prospective Population Study, taking up four health behaviors (exercise, moderate alcohol, not smoking, and regular fruit and vegeta- ble intake) can add 14 years of life expectancy (Khaw et al., 2008). But it is not clear that longer, healthier lives will lead to reduction in cost for the health care system. Pieter van Baal et al. used a dynamic population model to analyze health-care data from The Netherlands in order to estimate lifetime health-care cost conditional on the presence of risk factors. They found that expenditure was highest for the healthy (defined as: non-smoking, BMI between 18.5 and 25: health care cost from age 20 was estimated to be €281,000) and lowest for smokers (€220,000), with obese people in an inter- mediate position (€250,000), largely due to differences in the higher life expectancy of healthy people, and associated cost for care. However, there is dispute about whether increasingly higher life expectancy will in fact lead to higher levels of morbidity and care needs (the “medicalization thesis” [Wiener, Illston, and Hanley, 1994]) or whether longer life will mean that the phase of care needed is simply condensed over a shorter time than previously (the “compression thesis” [Metz, 2001; Kühn, 2005]), with some argu- ing that this will not lead to overall increases in health-care expenditure and others less convinced about possible savings (Niehaus, 2006). And questions about costs would also need to consider whether economic factors outside of the health-care sector should be considered in the form of health behavior–associated revenues (such as taxes) and losses (workdays due to sickness).

This is not the place to analyze in detail complex empirical or modeling data. However, it is noteworthy that some of the hard questions of distributive justice around people’s responsibilities may actually turn to a significant extent on an empirical analysis of actual costs associated with particular risk factors and ageing populations, which are often simply assumed. Regarding the possible options of how the cost question might be resolved within the more narrow focus of health care, it seems that if it should turn out that healthy living does indeed save health-care expenditure, prudence considerations aside, efficiency and solidarity considerations would make health promotion through bonus systems a legitimate aim in principle. Equally, if there


is equipoise, for there would still be the gain in quality of life. By contrast, in the situation where unhealthy behavior constitutes an economic advan- tage to sickness funds, the main rationale behind appeals to health behavior would appear not to rest on distributive justice grounds, but on fairness considerations, relating to avoiding opportunity cost (as care for an overall “cheaper” smoker, say, would typically still curtail resources that are available for the treatment of other diseases). Hence, possible negative assessments of people who fail to behave “responsibly” (in the senses implied by bonus programs that seek to encourage a healthy way of living) would need to be adjusted accordingly, as, to some extent, the argument can be made that they have “paid their way,” largely by dying earlier. Equally, the way such programs are advertised would need to be carried out in a way that avoided some form of unwarranted health paternalism or risk of stigmatiza- tion of already vulnerable groups, such as obese people.

A further general question concerns whether bonus systems are the right tool for the job of improving population health. Following Geoffrey Rose’s seminal 1985 paper “Sick individuals and sick populations,” the argument can be made that a focus on consumerist models and “over-dependence on individual choice will not achieve changes in society norms” (Doyle, Furey, and Flowers, 2006, 397) and will be to the detriment of the vulnerable and disadvantaged in society. Instead, broader public health measures should be promoted. One way of responding to this would be to argue that there is nothing wrong with a “both/and” approach, focusing on the underlying societal and other causes of disease as well as offering incentives to people individually. However, it is clear that at this point the equity test comes into play. For if bonus uptake is self-selecting, and consumerist initiatives increase in- equality, and if it is a declared aim of a health-care system to contribute to reducing inequalities, it may not be desirable to pursue both strategies.

Without further empirical evidence, it is difficult to decide whether the rationale of bonus programs of contributing to efficiency and equitable population health simultaneously is achievable, or whether, perhaps, their principal function is that of a marketing tool, helping sickness funds to attract and re- tain customers. If the latter was the case, health responsibilities implied by bonus programs might need to be viewed in a very different light. SGB V stipulates that bonuses must not be funded through higher insurance contributions but through savings that result from people’s improved health. Sick- ness funds are required to report in 3-yearly intervals on the operation of bonus programs to the relevant authority (the Bundesversicherungsamt, BVA), which, at the time of writing, is in the process of completing the first ever evaluation. Although the demonstration of cost savings over such a short time frame is nontrivial, early indications seem to suggest that the programs are in fact self-financing. However, clearly, this question needs to be considered in more detail in context of the final data of the initial

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analysis, on a case-by-case basis for each of the programs, and, perhaps more importantly, also over a longer time frame, in order to assess whether or not bonus programs have the effect of simply pushing cost forward in time.

In terms of feasibility, it is likely that the analysis by the BVA will also include an assessment of the administrative and organizational burden entailed for the sickness funds offering bonus programs. However, it seems improba- ble that this will have a significant impact on the general question of the bonus programs sketched above, as the assessments are relatively labor un- intensive. By contrast, in the case of Article 62 SGB V, concerning counseling about the potential of cancer screenings, the Gemeinsamer Bundesausschuss (G-BA), which was tasked with elaborating a guideline for the implementation of the law, cautioned that there was general absence of evidence that population-wide screening programs will lead to net savings (Gemeinsamer Bundesausschuss, 2007). So it remains to be seen whether the cost- containment rationale that the Government stressed in introducing the scheme will be feasible. It will depend largely on the extent to which the new rule will increase the numbers of those undergoing one of the three screens: if there is a very high uptake the screens may well increase, rather than decrease, overall expenditure, while not improving quality of life.

Solidarity

On one view it could be argued that bonus schemes have nothing but a positive effect on solidarity. For they incentivize and reward those who behave in ways that are assumed to make the health-care system more efficient, and the premiums are financed through the savings that are made in the process. As noted above, the truth of the economic element of this assumption de- pends to some extent on empirical evidence.

However, there is also a more conceptual point to be made. It is not im- plausible to assume that a sizable proportion of those who are eligible for bonuses would have behaved in the way that “earned” them the bonus anyway, simply because they follow a healthy way of living. In the “postbonus” phase, they therefore act no different than in the “prebonus” phase. Due to the risk-pooling system inbuilt in the financing of the statutory health insurance, in the prebonus phase they would then have contributed relatively more than in the postbonus phase, with expenditure remaining constant. In such cases, the introduction of bonus systems can be seen as eroding the notion of solidarity as one of “giving-without-expectation-of-return.” More- over, not only would preexisting inequity allow some to benefit more than others from bonus systems but the schemes would also exacerbate such inequalities. Certainly in the early phase of the introduction of bonus programs, this was the case: 19%, or almost twice as many people belonging to the fifth (least poor) quintile, used bonus programs in 2004/2005 as opposed to 11% of the first (poorest) quintile (Braun et al., 2006).


In a lesser sense, solidarity might also be undermined in that the merito- cratic element in bonuses might not be appreciated equally by all insurance holders. Those who are not able to mobilize themselves to actions for which bonuses are provided might envy those who do and find any competitive- ness at odds with a conception of solidarity that relates to a union of people who have come together to offer mutual support rather than join in a race for bonuses. Alternatively, finding that they are not able to perform bonus- rewarded behavior may result in a feeling of disappointment and perhaps lessen their self-esteem, sense of belonging to the solidaristic community, or feeling that their needs are being cared for appropriately.

Either way, it is clear that even if sickness funds should be persuaded that these risks are sufficient to reconsider offering bonus programs, doing so might also have a disadvantage. For those people who are most likely to be interested in bonus programs—the relatively well-off and healthy—may then be more tempted to seek a private provider instead of a public one. Retaining them, by contrast, would, at least in the short term, guarantee insurance holders with lower associated expenditures and comparatively higher contributions, benefiting, possibly, also poorer members of the solidaristic community.

Equality and Equity

Equity issues are raised in particular by the newly introduced Wahltarife. Al- though most bonus schemes can be used on a one-off basis, the minimum membership for all personalized plans is 3 years. It is only in exceptional circumstances possible to switch during this time. Sickness funds reserve the right to make adjustments to the level of bonuses or co-payments during this time, and insured persons may thus find themselves “trapped” in schemes that eventually turn out to be less attractive. This may have harsh consequences for those who were attracted to the plans because of the option of possible savings.

Bonus payments are limited to 20% of the annual contributions, but the schemes might nonetheless lead to a form of “health gambling”: if the insured persons stay healthy, they may make a gain. However, if they banked on redeeming the bonus and end up requiring treatment, they may either be faced with a financial “loss” of varying degree or, alternatively, may seek to avoid or delay necessary prescriptions or even a necessary hospitalization. It is also clear that this aspect is likely to make no-claim tariffs more attractive to some than to others. Although it might be of interest to the young and healthy, it will be less interesting to the elderly—unless they are very lucky gamblers.

The law is clear that medical appointments for routine checkups and preventative measures do not reduce the bonus in the case of no-claim schemes. However, patients, in particular those from disadvantaged groups of society, may be unsure about this and there is a risk that they are more reluctant to take part in these measures. This might jeopardize their health and could

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also have an effect that is diametrically opposed to the overarching focus on prevention and cost-containment that guided the most recent reforms.

Lastly, with several dozen major statutory sickness funds, each offering five defined plans as well as an open-ended number of further personalized plans, choice has certainly increased. But not all will be able to benefit from this choice, as people have different capacities and opportunities to ascertain which plans would be the most appropriate for their needs.

Intrusiveness

Bonus systems generally are not particularly intrusive, as they merely exist in the form of offers which insurance holders are free to take up. However, insurers differ in the way they advertise their programs, and it is not uncom- mon for insurance holders to receive frequent reminders by mail or other means. Such initiatives may be perceived as “nannying” of forms of “healthism” and may have a counterproductive effect on health responsibility attitudes.

Of the measures sketched above, those relating to presymptomatic checkups and in particular the scheme encouraging people to attend counseling sessions on cancer screens may also be intrusive in the sense that they bring uncertain and unwelcome knowledge about disease susceptibility, possibly leading to anxiety or confusion. The degree of intrusiveness can however be mitigated by focusing on providing information with suitable confidence intervals and the option for people to discuss any questions they may have.

Attributability and Opportunity of Choice

The majority of bonus systems involves relatively straightforward assessments of health-related behavior: people receive a bonus if they attend age- related health checkups or smoking cessation classes, go to the gym, or demonstrate that health relevant data are within a predefined range. Although the bonuses for the latter type of activity measure behavior in relation to particular health outcomes, in the majority of cases, rewards are given for merely anticipated future health outcomes: no evidence is required that the action for which the bonus was awarded has actually led to better health. It is simply the participation that is rewarded, and the bonus is not desert-based, in the sense that it is given irrespective of whether people would have behaved in the bonus qualifying way anyway or whether they made an extra effort and actively tried to be healthy.

A more complicated situation is given in the case of the cancer-screening policy, as “the bonus” of participating in counseling is linked with later health outcomes. Moreover, it consists not in a reward over and above a neutral baseline but in a reduction of co-payments from 2% to 1%. It can be helpful to approach the issue by assuming that in clear contrast to the current situation, we are faced with a (future or entirely hypothetical) situation


in which cancer screens have a negligible false-positive and false-negative rate, the cost of screening is low, and the cost of treatment can be reduced significantly by early detection and treatment. In such a scenario it can make sense to argue that the opportunity of choice matters, and that, while it would be wrong to force people to undergo screening, where they do not make use of it in a reasonable time frame—for whatever reason—the higher cost for later treatment should not fall exclusively on the solidaristic community. However, would this mean that those failing to attend screenings have lost any claim for assistance? A strict interpretation of Scanlon’s version of substantive responsibility could be interpreted as requiring this. However, such a policy would be at odds with the fundamental principle of solidarity that is at the heart of social insurance systems, and a solution in the form of co-payments might be legitimate in such an idealized scenario.

Although advances in technology may increase the accuracy of presymptomatic screens, clearly, the currently available tests vary considerably in terms of their confidence intervals, depending in particular on the age at which the screening takes place. Hence, it was right for the G-BA to reject the government’s initial proposal that would have made access to the lowest co- payment level conditional on undergoing the respective screen (Gemeinsamer Bundesausschuss, 2007). Firstly, on cost-effectiveness grounds, and secondly, because it would have imposed an undue psychological burden on those undergoing the screens with the primary aim of limiting possible future co-payments.

But what should we make of the final G-BA proposal that then became policy and links lower co-payments with attending counseling about the advantages of the screens within 2 years of eligibility? I will explore here the thought that it is acceptable in one way and less so in another. Provided that counseling is nondirective, that the ultimate decision about whether or not to undergo the screen is genuinely up to the people concerned, and that people have been invited by appropriate means and had reasonable opportunities to attend a counseling session within the required 2 years after becoming eligible (which would depend on the availability of counselors in the region, and at appropriate times, etc.), it is plausible to argue that the policy can be acceptable. For, the ultimate decision about undergoing the screen needs to be made by the persons concerned, especially since the screens are beset by some uncertainty. But few people spend their Saturday afternoons thinking about whether or not to go for a colon cancer screen, even if they know they should. Hence, the conditionality can work both as a mobilizer that can help people develop their judgment on health matters (becoming “gesundheitsmündig,” as Sass [2006] puts it) and thus has prudential benefit, as well as permitting potential cost-containment through early detection and treatment of diseases.

However, it is far less clear whether the financing principle behind the current policy should be acceptable. The standard cap for annual

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co-payments for all insured people in statutory sickness funds is 2% of one’s annual gross income. The option of reducing this to 1% has some attraction. However, it needs to be seen in the context of the rule for the “ordinary” chronically ill, who only pay 1% by default. So, the “incentive” or bonus has simply been created by doubling the base rate—but it could equally have been implemented as, for example, an option of halving the “standard” 1% chronically ill co-payment level to a 0.5% rate. It is far from clear how the increase to 2% is justified by reference to the “special personal responsibilit[ies]” (Bundesregierung, 2006, 305) of some chronically ill people, as suggested by the government in its justification of the revised law. I am leaving aside here the question of whether even the 1% threshold is—actuarially or otherwise— warranted, but the primary point is that it is more than odd to create bonus- options for some patient groups by increasing the base level that is generally thought to be appropriate for the group as a whole. It is moreover unfair, as it disadvantages those eventually suffering from one of the three cancers, who, arguably, are as much chronically ill as those suffering other diseases.

Affected Third Parties

For the most part, the administration of bonus programs does not involve third parties, as the insured generally report their qualifying behavior directly to the sickness fund. In the case of dentist visits, reception staff may log the dates electronically, and the determination of other types of bonus qualifying behavior may involve health-care staff, for example, they are required where rewards are made if key health data such as blood pressure, etc. stays within a certain range over a year. Those on no-claim plans may wish that health care staff was not involved, if they require treatment before comple- tion of the qualifying period, and issues may arise where patients appeal to staff not to record their appointment. Most of these situations are, however, likely to just lead to awkward situations. A more problematic situation can be given in the case of the above-mentioned cancer-screening program: conflicting goals may arise for health-care professionals in the sense that counseling is to be offered by medical professionals who are also qualified to carry out the respective screens. While, clearly, this can be a good thing, it may pose problems where counselors are overly enthusiastic about the technology. The potentially most problematic implications arise from the re- quirement of making the lowest co-payment threshold conditional on an annual certificate that confirms compliance, which may put the doctor in an actual, or perceived, policing position and may hence have a detrimental effect on the doctor-patient relationship.

Coherence

The coherence test is more relevant for cases where sanctions for contributions to a bad health outcome are contemplated. In the case of bonuses, a


comparison to other policies, such as reward cards in shops, or car insurance, emphasizes again the consumerist, market-driven element of such policies.

VI. CONCLUSION

The framework presented here has shown that bonus systems give rise to different kinds of ethical tensions. Although, in principle, a market-based approach need not be incompatible with the values underlying social health insurance, the consumerist concept inbuilt in bonus programs has worrying implications for equity and solidarity. Bonus payments relying on self-selection have a clear tendency to negatively affect the risk-pooling principle and to reduce the funds available to the solidaristic collective. The benefits are in practice unlikely to be available to all. In particular, those who are already in disadvantaged or vulnerable positions stand to gain far less. In this sense, bonus systems betray their name and are not as good a thing as the label suggests.

In terms of promoting responsibility, bonuses can be said to achieve little where they are awarded for behavior that people would have displayed anyway (whether because they were sufficiently self-motivated or just had the right habit). It was shown that a program seeking to incentivize people to contribute to overall efficiency by attending counseling sessions on cancer screens could be seen as appealing to a legitimate sense of substantive responsibility, in principle. However, its implementation which rested on the option of reducing co-payments from 2% to the general level for all other chronically ill of 1% in the case of suffering a screening-related disease was unjustified.

Nonetheless, it would be premature to conclude that bonus systems should be abandoned. As noted, the first ever-economic evaluation of the overall effectiveness of bonus programs is still to be published, and a close assessment of this data is required in view of the ethical issues raised by bonus programs, including those flagged in this paper. It also appears that other mechanisms beyond that of self-selection could be adopted. It would not be conceptually impossible, for example, to offer bonuses only for the least well-off. This might help make progress toward the aim of improving population health and reducing health inequalities, even if bonuses might then become less interesting as a marketing tool for attracting and retaining the cheapest insurees (in the short or medium term). In any case, it seems clear that the burden of proof that bonus systems are a useful way of promoting health responsibility is on the side of the advocates of these programs.

ACKNOWLEDGEMENTS

I am most grateful for discussions of particular points with Stefanie Ettelt, Nicole Knaack, Elias Mossialos, Alex Voorhoeve, and Joy Wang. The usual caveats apply. The views expressed here are the author’s alone and must not be attributed to LSE Health or the Nuffield Council.

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NOTES

1. See Roemer (1994; 1995), Arneson (1997), and Dworkin (2000). 2. See Callahan (1999). 3. See Engelhardt (1976). 4. See English (2005), Iltis and Rasmussen (2005), and Schmidt (2007b). 5. See Wikler (1978), Wikler (2004), Cappelen and Norheim (2005), Feiring (2008), Gauthier (2005),

and Kelley (2005). 6. See Houtepen and Meulen (2000b). 7. See Schmidt (2008).

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Bonuses as incentives and rewards for health responsibility: a good thing?

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