The economic benefits of health and prevention in a high-income country: the example of Germany

This paper complements the current health policy debate, which is largely confined to the cost aspects of health systems, by considering explicitly the potential economic benefits of investing in health in general and via - chiefly primary - prevention. While concerns about high and rising health care costs are justified, we see a pressing need to also measure the benefits, ultimately enabling a complete economic assessment of the socially optimal level of resources for health. Despite the use of Germany as our point of reference, our approach and findings likely apply to a wider set of European highincome countries. Using new and already existing data, we find that in sheer health terms Germany has a lot to gain from more and better illness prevention. Assuming part of this existing burden can be reduced via effective preventive interventions, we find that the resulting economic benefits - expressed in people's willingness to pay for a reduction in mortality risk - would be substantial. We also gather Germany-specific evidence to suggest that the existing burden of ill health - whether caused by lack of prevention or treatment - negatively impacts a number of important economic outcomes at the individual and macro-economic level. Referring to work carried out in parallel to this project, we find that a number of cost-effective, primary preventive interventions exist to tackle part of the avoidable disease burden. Yet we note a deficit of economic evaluations, in particular in non-clinical interventions - a finding that underlines the role of government in the production of research on specifically non-clinical prevention. In light of the market failures discussed, from an economic perspective the role of government not only consists of research, but also - surprisingly to many - extends to actual interventions to address the health behaviour-related determinants of chronic disease. With the stakes as high and the economic justification for action in place, the case for scaling up preventive efforts in Germany, backed up by solid epidemiological and economic research, is hard to deny. -- Die vorliegende Studie ergänzt die gegenwärtige gesundheitspolitische Debatte, die sich vorwiegend auf Kostenaspekte des Gesundheitswesens konzentriert, indem sie den potentiellen ökonomischen Nutzen von Gesundheitsinvestitionen im allgemeinen und (Primär-)Prävention im besonderen hervorhebt. Auch wenn die Sorge um hohe und steigende Kosten des Gesundheitswesens berechtigt ist, bleibt die Notwendigkeit, auch den Nutzen der Gesundheitsausgaben zu erfassen, um somit zu einer ökonomisch vollständigen Einschätzung des sozial optimalen Niveaus der Gesundheitsausgaben zu gelangen. Trotz des Fokus auf Deutschland sind unser Ansatz und die Ergebnisse auch auf andere Mitgliedsländer der EU übertragbar. Wir zeigen anhand neuer und schon bekannter Daten, dass der Spielraum für Gesundheitsverbesserungen, vorwiegend durch Prävention, in Deutschland erheblich ist. Der ökonomische Nutzen - gemessen an der Zahlungsbereitschaft der Bevölkerung - der durch Reduktion eines Teils dieser Krankheitslast mittels Interventionen erzielt werden kann, ist nach unseren Berechnungen beachtlich. Darüber hinaus zeigen mehrere Studien, wie die aktuell gegebene Krankheitslast, ob durch einen Mangel an Prävention oder Versorgung verursacht, eine Reihe relevanter ökonomischer Grössen auf individueller und gesamtwirtschaftlicher Ebene beeinträchtigt. Wie eine parallel durchgeführte Studie der Autoren ergab, existieren auch eine Reihe kosten-effektiver Interventionen im Bereich der primären Prävention. Dennoch bestehen noch Lücken in der ökonomischen Bewertung insbesondere nicht-klinischer Interventionen - ein Ergebnis, das die Rolle des Staates in der Evaluation dieser Interventionen unterstreicht. Aufgrund von Marktversagen in einigen relevanten Bereichen besteht eine ökonomische Rechtfertigung für staatliches Handeln nicht nur im Bereich der Forschung, sondern - überraschend für manche - auch im Bereich der (Primär-)Prävention der nicht-ansteckenden und mit dem individuellen Gesundheitsverhalten verbundenen Krankheiten. Aufgrund des in diesem Papier dokumentierten hohen gesundheitlichen und ökonomischen Nutzens sowie der ökonomischen Rechtfertigung der Rolle des Staates kann das Argument für eine Verstärkung der Prävention in Deutschland nur schwer bestritten werden.

Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial.

IntroductionObesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals' utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual's skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone.Methods and analysisWe are recruiting 795 adults, aged 18-70 years with a body mass index ≥30 kg/m2, from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months.Ethics and disseminationHuman research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View-UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders.Trial registration numberNCT03157713

Neurocognitive measures of impulsivity: explanatory, diagnostic and a prognostic role in obesity

Obesity is a growing public health problem with multiple aetiological factors. Behavioural determinants are likely to be key contributors to obesity, with a need for applied research in this field. Recently the obesity has been compared to food addiction with the connotation that obese individuals are impulsive in their behaviour. Impulsivity is a trait that is closely linked to addiction and has been studied in personality, psychiatry and more recently in the neurocognitive arena. A conceptual review of the construct of impulsivity identified inhibitory control (SST) and temporal discounting (TD) as two key behavioural constructs universal to all the key fields of impulsivity research. A systematic review of the literature supported their use to profile participants based on their Body Mass Index. The validity of the tools were proven by endophenotyping participants (N=202) of both normal weight and those seeking weight loss intervention. Both measures could successfully differentiate between obese and normal weight adolescents (N=85). The SST was also prognostic for short-term weight reduction in adolescents attending a lifestyle intervention, with the TD being able to predict weight loss maintenance at 6 months. The tasks could not differentiate significantly between adults of different weights but the TD was able to predict weight reduction after surgery (N=90). The modifiability of obesity through neuronal dopamine pathways was supported by a randomised controlled trial testing neurocognitive enhancement agents (N=40) against a placebo (N=40) in normal weight adults. Weight was also controlled by a commitment intervention targeting automatic impulsive behaviours (N=27). These findings support an association between impulsivity, obesity and weight reduction. The experimental inferences have been described in terms of a novel interconnected neuronal network, which leaves itself open to testing using functional brain imaging.Open Acces

Assessing the Influence of Coronary Heart Disease Knowledge, Perception of Personal Risk, and Delay Discounting of Future Health on Diet and Physical Activity

Although modifiable risk factors for coronary heart disease (CHD) can be favorably impacted by healthful diet and physical activity, health care providers face a population that generally exhibits unhealthy eating habits and sedentary lifestyles. Identifying strategies to improve the effectiveness of health care provider guidance is urgently needed to reduce CHD risk. The objective of this series of studies was to determine the association between CHD knowledge, perceived risk, and delay discounting and diet and physical activity (PA) levels in adults. The research design was cross-sectional and the methods included an online survey to obtain information regarding CHD knowledge, perceived risk, and preventive behaviors and a binary choice discounting procedure to elicit degree of discounting for hypothetical monetary and health rewards in an Appalachian population. The specific aims of the studies were: (1) To determine the association between knowledge and perceived risk of CHD and diet and PA in Appalachians, and (2) To evaluate the association between the degree of discounting of future health and diet and PA. In the first two studies, overall knowledge of CHD was positively correlated with both healthfulness of diet and PA levels, but these associations were no longer significant after controlling for demographic factors and other components of the HBM, including perceived risk of CHD, perceived severity of CHD, perceived benefits and barriers to preventive behaviors, self-efficacy, and cue to action. Contrary to the direction of association predicted by the HBM, perceived risk was negatively associated with diet and PA behaviors. Age, perceived barriers, self-efficacy and physician recommendations for lifestyle changes may also play a role based on their significance as predictors of dietary or PA behaviors. In the third study, degree of delay discounting was not associated with CHD preventive behaviors, specifically diet and PA. Perceived risk was negatively associated with preventive behaviors, but no association with degree of discounting was shown. When associations between value of the future and preventive behaviors were explored by BMI category, a positive correlation was demonstrated between value of the future and dietary behavior in underweight/healthy participants, but no association was found in overweight/obese participants

The Economics of Risky Health Behaviors

Risky health behaviors such as smoking, drinking alcohol, drug use, unprotected sex, and poor diets and sedentary lifestyles (leading to obesity) are a major source of preventable deaths. This chapter overviews the theoretical frameworks for, and empirical evidence on, the economics of risky health behaviors. It describes traditional economic approaches emphasizing utility maximization that, under certain assumptions, result in Pareto-optimal outcomes and a limited role for policy interventions. It also details nontraditional models (e.g. involving hyperbolic time discounting or bounded rationality) that even without market imperfections can result in suboptimal outcomes for which government intervention has greater potential to increase social welfare. The chapter summarizes the literature on the consequences of risky health behaviors for economic outcomes such as medical care costs, educational attainment, employment, wages, and crime. It also reviews the research on policies and strategies with the potential to modify risky health behaviors, such as taxes or subsidies, cash incentives, restrictions on purchase and use, providing information and restricting advertising. The chapter concludes with suggestions for future research.

Handbook of Health Economics

Editors and authors should be complimented for their impressive attempt to provide a fair account of the state-of-the-art in health economics. To review such an extensive work in a short time span, we decided to select certain chapters for more in depth study. This selection was based on our areas of expertise under the restriction that all major research areas distinguished in the handbook should be covered. Before turning to the review of the separate chapters, let us first make some general comments about the handbook. An important first question is whether all relevant research areas are covered and whether this has been done in a balanced way. Of course, exhaustive coverage in one book is unattainable for a large area like health economics. Rather the question is that regarding balance and possible lack of bias. In that respect, the book focuses on the US literature and health care system with 24 chapters written by US authors and only 11 by European and Canadian authors. The more traditional economic areas are generally covered by the US authors, emphasising a neo-classical rather than an institutional paradigm, and boundary topics like ‘equity’ and the ‘measurement of health’ are covered by the non-US authors. This structure both reflects the contributions in the health economics literature and the large variation in US health care institutions, and is on

An Economic Framework for User Financial Incentives for Health Behaviour Change

Background: Diseases such as stroke and heart disease are chiefly caused by unhealthy behaviours and are a major societal burden. User financial incentives are being explored as a way to encourage healthier lifestyles. This research developed a framework to provide information on pricing and cost-effectiveness of incentives and guide design of future incentive schemes. Methods: The workstreams were: a) structured, configurative literature review to identify neo-classical/behavioural economic explanations for behaviour change and incentives; b) contingent valuation survey to identify willingness to accept (WTA) and incentive pricing; c) systematic review and meta-analysis of incentives for weight loss; d) development of decision-analytic model to estimate cost-effectiveness of incentives for weight loss. Results: The reviews identified a number of factors important for understanding the effect of incentives including internal motivation, self-control and time preference. A theoretical framework of incentive impact was developed to facilitate WTA survey design. The WTA survey was completed by 112 people (n=56 at 3 months). 57% strongly disagreed with incentive use. The mean incentive required per month depended on behaviour, ranging £103.69 for smoking cessation to £45.43 for reducing alcohol intake. The most important predictors of WTA were self-control, perceived difficulty of change and attitudes to incentives. There was some evidence that WTA incentives increased over time. Review and meta-regression provided efficacy parameters for the decision-analytic model which comprised the following health states: healthy, type II diabetes, stroke, myocardial infarction and dead. Analyses from NHS and employer perspectives indicated incentives for weight loss are cost-effective over a lifetime as they dominated usual care. Discussion: Incentives may be most powerful if they are personalised to account for individual factors and attitudes and are dynamic in response to these. Incentives may be cost-effective in a number of scenarios. Further research is required on the long term outcomes of incentives and financing models