The New York Times Readers’ Opinions About Paying People to Take Their Medicine

Abstract

Background. There has been considerable interest in using financial incentives to help people improve their health. However, paying people to improve their health touches on strongly held views about personal responsibility. Method. The New York Times printed two articles in June 2010 about patient financial incentives, which resulted in 394 comments from their online audience. The authors systematically analyzed those online responses to news media in order to understand the range of themes that were expressed regarding the use of financial incentives to improve health. Results. The New York Times online readers revealed a broad range of attitudes about paying individuals to be healthy. Many comments reflected disdain for financial incentives, describing them as “absurd” or “silly.” Other comments reflected the notion that financial incentives reward individuals for being irresponsible toward their health. Many individuals communicated concerns that paying individuals for healthy behaviors may weaken their internal drive to be healthy. A smaller set of comments conveyed support for financial incentives, recognizing it as a small sum to pay to prevent or offset higher costs related to chronic diseases. Conclusions. Although a measurable group of individuals supported financial incentives, most readers revealed negative perceptions of these approaches and an appeal for greater personal responsibility for individual health. Despite experimental success of financial incentives, negative perceptions may limit their public acceptability and uptake.

Keywords

chronic disease management health policy health promotion media qualitative methods

There has been considerable interest in helping people improve their health through financial incentives. Recent studies have demonstrated that paying people to lose weight, quit smoking, or take their medications have helped patients achieve those goals (Volpp, John, et al., 2008; Volpp, Loewenstein, et al., 2008; Volpp et al., 2009). In fact, paying people to quit smoking has an effectiveness that compares favorably to a variety of pharmacologic approaches to nicotine addiction (Volpp & Das, 2009). From that perspective, financial incentives can be viewed as another treatment option alongside conventional medical therapies. However, research has demonstrated equivocal support toward the use of patient financial incentives (Long, Helwig-Larson, & Volpp, 2008). Helping people improve their health by paying them to do what is already in their own best interests may touch deeply held views about personal versus social responsibility for health. Even if people agree on the goals of improving health, some individuals may disagree on approaches that are appropriate for achieving those goals.

Perhaps for these reasons, research in using financial incentives to improve health has attracted public attention. For example, The New York Times has reported on this issue frequently, including a June 13, 2010, front page article highlighting a study using financial incentives to improve warfarin adherence (Belluck, 2010; Lohr, 2010; Rabin, 2010). Warfarin—a medication used to prevent blood clot formation—is often used to reduce the risk of stroke in patients with atrial fibrillation. That article reported on a study in which patients participated in a daily lottery allowing them to win a monetary prize—received only if they took their warfarin the day before. Medication adherence among patients receiving the financial incentive was nearly 10 times higher when compared with care without incentives. When the incentive was removed, many of the patients reverted to their original habits of inconsistent adherence (Volpp, John, et al., 2008).

The article in The New York Times elicited many postings from their online readership. Later that day, The New York Times published a collection of five commentaries from experts in bioethics and health policy, providing differing views of the positive and negative aspects of financial incentives in this setting (The New York Times Editors, 2010). These commentaries also elicited a large number of online comments reflecting wide-ranging opinions about the use of financial incentives to promote healthy behaviors.

Despite the growing interest in the use of financial incentives to improve health behaviors, research in this area is limited. Most studies revealed limited support for the use of patient-directed financial incentives because of concerns related to loss of personal responsibility in health and the appearance of rewarding unhealthy behaviors while penalizing the healthy (Bonevski, Bryant, & Paul, 2011; Long et al., 2008; Lynagh, Bonevski, Symonds, & Sanson-Fisher, 2011; Promberger, Brown, Ashcroft, & Marteau, 2011; Reisinger et al., 2011).

In this study, we systematically analyzed the content of readers’ comments to understand the range of themes in this area. Those posting comments are readers of The New York Times and only those sufficiently motivated to respond. For that reason, these comments are unlikely to represent the overall population. Nevertheless, computer-mediated communication has been shown to provide emotional content similar to face-to-face communication along with enhanced sincerity and truthfulness of sentiments conveyed in online comments (Derks, Fischer, & Bos, 2007). Few studies have used online comments in their analyses, with most studies investigating posting patterns (Krishnamurthy, 2002) or measuring emotion through content analysis of the comments (Mishne & Glance, 2006). However, no study has used online comments to understand public sentiment. Our study makes use of this rich data source, demonstrating the potential value and limitations of using online responses to gain insight into public sentiments about issues in health care. Given the frequency of the comments in response to The New York Times articles, and their individual depth, the collection is useful to explore a range of public sentiment about financial incentives in health.

Method

Data Sources

The first New York Times article, “For Forgetful, Cash Helps the Medicine Go Down” by Pam Belluck, was published online June 13, 2010, and had 217 reader comments posted by June 14, 2010, at which point the forum was closed to new comments (Belluck, 2010; Readers’ Reviews, 2010a). The second article, “Should People Be Paid to Stay Healthy,” was published on June 14 (updated June 15), 2010, and contained five expert commentaries that elicited 177 reader comments from June 15 to June 28, 2010 (The New York Times Editors, 2010; Readers’ Reviews, 2010b). After a week of no posting activity, the comments for both articles were assembled into the data set.

To post a comment, readers log in using a NYTimes.com account. Accounts are free to create and require users to provide information on gender, year of birth, zip code, country of residence, household income, job title, industry, and company size. Separate from their account profile, readers are free to type in a display name and location for each comment they post. Because the display name and location fields are open text boxes, readers who comment have varying degrees of anonymity. Comments are limited to 5,000 characters, time stamped, and moderated before they appear online but are not edited (The New York Times, 2010). NYTimes.com moderates readers’ comments to ensure they are “on topic and not abusive” (The New York Times, 2010). Data on average NYTimes.com readership was obtained from The New York Times’ Media Kit page for advertisers (Nielsen NetRatings, 2009). However, characteristics of individual respondents are not known.

Data Analysis

Using the grounded theory approach to qualitative data, the content of these postings was systematically analyzed. First, three reviewers read comments from both articles to identify common themes. Second, to ensure that each reviewer coded comments appropriately, a small set of randomly selected comments was used as a training set. Two reviewers reviewed the items in the training set together to assign themes to each of the comments. Comments could be assigned multiple themes or none at all. Through that process, the original set of themes was modified to a more consistent set to which all reviewers agreed. Third, the remaining comments comprised the evaluation set, and the two reviewers worked independently to code the comments. Fourth, for comments with differences in coding between the two reviewers, a third reviewer was used to adjudicate the disagreement to finalize the final coding for the presence or absence of themes. The coding of all comments was combined into a single set for analysis. To measure how well the two reviewers agreed in their independent coding of each comment, interrater reliability via kappa scores were calculated for each of the themes using STATA 11.1.

Results

Study Participants

General demographic information regarding the online readership of The New York Times is shown in Table 1 (Nielsen NetRatings, 2009).

Table 1.

Demographic Profile of the NYTimes.com Readership (Nielsen NetRatings, 2009)

	Audience Composition (%)
Adults
Women	48.9
Age (median = 47 years)
18-49	57.2
25-54	62.8
35 and older	75.1
Income (median = $75,265)
$75,000 or higher	48.6
$100,000 or higher	30.7
Education
Any college or more	84.3
Any graduate college or more	54.5
Occupation
Professional/managerial/executive	55.4
Education	6.6
Technical	6.7
Self-employed	5.0

Comments and Themes

A total of 217 comments were made in response to the article and another 177 comments were made in response to the five commentaries. Because both sets of comments revealed the same range of themes, all 394 comments were combined into a single data set. Twelve themes were identified and organized into four main categories, as shown in Table 2. To illustrate readers’ sentiments, exemplars follow the presentation of each theme. The average number of themes assigned to any comment was 1.5 and ranged between 0 and 6. Kappa scores reflecting agreement between the two coders for each of the 12 themes ranged between .45 and .75 with a mean of .64, indicating generally good agreement.

Table 2.

Identified Themes, Grouped by Topic, and Their Frequencies

Topic	Theme	Percentage of Total Comments
Alternative incentive types	Good health should be the ultimate incentive.	10
	Penalties, fines, or incentives aside from money should be used as an incentive.	20
Ethical and social issues	Financial incentives reward people for irresponsibility for which they should face the consequences.	21
	Financial incentives indirectly penalize people who have good health habits.	10
	Financial incentives to promote health will ruin the future of society or make people worse in the long run.	6
	People will game the system to win the financial incentive.	3
	Financial incentives are paternalistic.	4
Negative public perception	People make moralistic judgments and/or negative assumptions about individuals who use financial incentives to improve their health.	11
	People think the government is involved in financial incentives.	11
	People distrust the health profession and the services they provide.	12
	The idea of paying people to take medications is absurd, crazy, outrageous, ridiculous, etc.	25
Positive public perception	People support the use of financial incentives.	13

Alternative incentive types

Many readers recommended alternative incentives to promote healthy behaviors. Any comment that supported other incentive schemes was included in this category. Of the 394 comments, a total of 110 (28%) comments were coded as such and further classified into 2 distinct themes. The first theme (10%) reflected the view that good health should be sufficient incentive for healthy behavior:

The life-saving effects of her medication are not a good enough incentive? If she can remember that if she takes her medication, she might win some money, she should be able to remember that if she takes her medication she might continue to be around to watch her little boy grow up.

Even more comments (20%) reflected the view that penalties, fines, or incentives aside from money should be used as an incentive:

What if patients were FINED each month for not taking their medication? Certainly the incentive would still be in place.

Ethical and social issues

Financial incentives raise many ethical and social issues regarding their use to promote health. A total of 141 (36%) comments were included in this category and separated into five themes. A large number of comments (21%) reflected the idea that financial incentives reward individuals for being irresponsible regarding their health:

So theoretically this could mean that my premium will, in some form, be used to pay someone to take medications because they don’t have the willpower to do what they have to do on their own? . . . Somehow this logic doesn’t make any sense. It seems like we’re going to reward people for being lazy and stupid to begin with. . . . If someone refuses or forgets to take their medication, that’s their own damn problem.

Other comments (10%) reflected a view that financial incentives indirectly penalize healthy individuals whose insurance premiums would help fund the financial in- centive:

Disgraceful. This is the problem when you have free medical care for all. No responsibility or accountability for ones actions. The responsible members of our society must constantly pay the price for the stupidity of others. And the price is getting higher every day.

A small set of comments (6%) reflected a concern that financial incentives used to promote health will ruin the future of society or make individuals who use them worse in the long run:

Just how far will we take the nanny state? With each act that “we” as a society take to mitigate personal responsibility, we create ever more inept and dysfunctional fellow citizens. Eventually, we’ll all need “someone else” to do all of our decision making for us. As with all life on this planet, we are only here as a direct result of survival of the fittest. . . . Either accept that people must live, or die as a result of their actions, or help to create a pathetic future filled with pathetic people.

The next set of comments (3%) conveyed concern that individuals will game the system, or intentionally alter their behavior to obtain the financial incentive:

I pay for the prescription and then I get paid to take the medicine? This sounds like a shell game with lots of opportunities for fraud and deception. . . . I just know that when money is involved, sick people may manipulate the system. I can easily imagine people . . . thinking “Hmmm, let me see how I can make this work for me.”

Last, some comments (4%) reflected the view that financial incentives are paternalistic, or unduly coercive, to individuals who seek them out:

I would be concerned that the next step after offering incentives to comply with prescribed medication/losing weight/quitting smoking would then be forcing people to take medication or denying people jobs because their cholesterol levels aren’t what the current medical profession describes as ideal, regardless of more objective measures of health and performance.

Negative public perception

Individuals expressed varying negative perceptions and opinions regarding the use of financial incentives for health. A total of 181 comments (46%) revealed these opinions regarding the use of financial incentives for health and were also categorized into four themes.

The first theme (11%) in this area reflected moralistic judgments or negative assumptions about individuals who use financial incentives for health:

What a dumb idea. When [do] people realize they have to be responsible for their own actions? We’ve become [a] socialist state. We can’t help everyone, especially those [who] are too stupid or don’t care enough to help themselves.

Other comments (11%) reflected concern that the government was involved in the implementation of financial incentives:

If this government doesn’t stop coming up with stupid ideas for spending money, I’ll scream! . . . it is NOT their job to dictate individual lives or take care of stupid citizens that cannot take their medicine. . . . Get real! This country is about individual responsibility.

Even more comments (12%) reflected distrust of the health profession and/or the services it provides:

This is a terrible idea from which Big Pharmas, insurance companies, doctors and hospitals will be the real profiteers. Many people no longer trust the FDA or their doctor’s advice and with good reason. There is far too much collusion between doctors, pharmaceutical companies and insurers in America and the public are right [to] be wary of all the “must use” drugs being perpetuated upon an often unwary American public.

The largest set of comments (25%) reflected disdain for the overall concept of using financial incentives:

This is absolutely ABSURD!!! I seriously can’t believe that there are so many people out there who need to be treated as children! Next we’ll be trying to figure out how to incent people to brush their teeth before bed and eat all their veggies! This is the way you treat three-year olds, not the adult population.

Positive public perception

Despite the large number of negative perceptions of financial incentives, 52 comments (13%) clearly reflected support for the use of financial incentives to promote healthy behaviors:

I’ve read a number of the comments posted here, and I think everyone seems to missing the point of the study and incentives. . . . I know firsthand how big of a problem non-adherence can be. The cost on the healthcare system is astounding (anywhere from $100-250 billion a year). Patients who do not take their medications, for whatever the reason may be, are costing the U.S. billions of dollars in associated costs because they usually become more sick or have emergent problems which means hospitalization.

Discussion

This study analyzing online comments of two New York Times articles has three main findings. First, a majority of comments revealed considerable concern about using financial incentives to help people take their medication. Second, despite these concerns, a small portion of comments reflected support for the use of financial incentives. Third, this study demonstrates a novel approach to understanding a range of public sentiments through the use of online postings. While the specific percentage of comments is difficult to interpret because of the nonrandom selection of participants, the underlying themes reflected in these comments help provide a range of thought in these areas.

A large portion of comments reflected negative views about the use of financial incentives to improve medication adherence. Many of these negative views concerned the threat to personal responsibility in health that financial incentives might impose in seemingly rewarding unhealthy behaviors. Nevertheless, those negative views should be interpreted in the context in which the data were collected—in particular, the analysis of comments spontaneously written in response to newspaper reporting. These settings are more likely to generate negative rather than positive comments. Chmiel et al. (2011) have demonstrated that comments with negative emotion tend to increase commenting activity by online users and become key agents to sustaining online discussions. Hence, the frequency of online negative comments likely overstates the opinion one would achieve through representative sampling.

At the same time, although the relative frequency of negative themes may not be a true reflection of public sentiment, the content within the comments may reveal more honest, uninhibited sentiments about financial incentives. Derks et al. (2007) concluded that the anonymous nature of posting comments enhances users’ abilities to express both negative and positive comments, allowing individuals to post more overt and explicit comments. In addition, computer-mediated communication provides a safer medium than face-to-face communication to express more personal thoughts (McKenna, Green, & Gleason, 2002). Online comments made by readers of The New York Times may reflect more personal and less censored thoughts that might not be revealed in traditional focus groups that use face-to-face communication.

Many individuals posting comments offered alternative incentive schemes to mitigate the dissonance between financial incentives and personal responsibility. The most prominent suggestion was the idea of using penalties or fines to promote healthier lifestyles. Unlike reward-based incentives, a penalty-based incentive structure allows incentives to remain in place while preserving principles of personal responsibility. The threat of a penalty places the risk and reward solely on the individual, unlike monetary reward incentives that may involve contributions from other people. Because it endorses personal responsibility, a penalty system may be more palatable to the public. However, a study of patient opinions regarding financial incentives demonstrated less favorable support for penalty-based incentives (Long et al., 2008). In other settings, concerns have been raised that such penalties risk discriminating against the unhealthy, worsening health disparities, or stigmatizing and marginalizing individuals (Bishop & Brodkey, 2006; Blacksher, 2008; Pearson & Lieber, 2009; Steinbrook, 2006).

In contrast to these concerns was clearly expressed but minority support for the use of financial incentives. Many individuals recognized financial incentives as a small sum to pay to prevent or manage chronic medical conditions such as hypertension, hyperlipidemia, or diabetes. In the case of warfarin use for atrial fibrillation, financial incentives may improve medication adherence, enhancing the therapeutic benefits of the drug and minimizing the risk of costly complications. Some of those commenting recognized that financial incentives may help offset those costs. Unhealthy behavior patterns are estimated to result in more than 900,000 deaths in the United States each year (McGinnis, Williams-Russo, & Knickman, 2002). Financial incentives offer promise in mitigating these behaviors.

Our study is the first to perform a large-scale qualitative investigation into public perception of patient-directed financial incentives. We used a novel approach by analyzing comments in response to online news media. One concern in using such a source is the influence of the news article on individuals who comment (agenda setting theory). Some readers may perceive a heightened sense of importance regarding the use of financial incentives simply because the news reported on it. Others may be influenced by the information contained within the articles, which may alter the content of their comment. However, our thematic findings are consistent with previous qualitative studies about financial incentives—all showing concern for personal responsibility in health and low levels of support for their use (Bonevski et al., 2011; Lynagh et al., 2011; Reisinger et al., 2011). This consistency between studies supports the validity of our findings.

This study demonstrates some of the uses and limitations of using online postings as a window on public opinion. This study is subject to several limitations. As we have noted, individuals who post online comments are unlikely to be representative of the population as a whole. The online audience of The New York Times has a median income of more than $75,000 and more than 84% of that readership has some college education. Even within that readership, only selected readers will post comments—perhaps those with greater senses of outrage—and The New York Times moderates which comments are posted to their website to remove off-topic and offensive postings (The New York Times, 2010). Despite these concerns about population representativeness, the comments as a whole reveal considerable breadth of opinion. Unlike traditional focus groups using face-to-face communication, these online comments provide less inhibited content from a large audience that might not be achievable otherwise. Broader audiences might reveal a different distribution of these sentiments, though perhaps less likely a different set of themes. This study also has several strengths. The content of postings was systematically analyzed using two independent reviewers. The postings themselves were reactions to articles tightly focused on the topic of interest. As in any conversation, comments could reflect reactions to the underlying articles blended with reactions to the earlier comments. They are comments provided within the context of an online linear “discussion” of the issues. The large number of postings increased our confidence in the identification of the themes.

The Affordable Care Act expands the ability of employers to offer financial incentive to their employees for achieving certain health benchmarks (Volpp, Asch, Galvin, & Loewenstein, 2011). However, public support for this approach remains uncertain. Expanding qualitative work in this area to a more diverse sample may provide additional insight into public perceptions of financial incentives that may not have been apparent.

In summary, this study, taken from a naturalized setting of newspaper readers, reports public sentiments about the use of patient financial incentives to improve health. Using a novel approach of systematically analyzing online postings in response to newspaper articles, the nearly 400 comments revealed largely negative perceptions of financial incentives and an appeal for greater personal responsibility for individual health. Despite the negative perceptions, there was concurrent support for the use of financial incentives, particularly from individuals who recognized good health practices may avert higher health care costs for chronic conditions later in life.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:

James Park was funded by a NIH training grant (T32-HP-10026), which had no role in the design, conduct, analysis or manuscript preparation.

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