Empirical testing of a widely available insurance-based monetary incentive program for exercise: A randomized trial

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Participation in regular physical activity (PA) has numerous health benefits including reduced risk of all-cause mortality,1-7 cardiovascular disease,8-12 diabetes,13-16 and cancers of the breast17-19 and colon,20-23 as well as energy balance.24 However, only 54% of U.S. adults meet national guidelines of expending > 1000 kcals/week through PA,25 and as few as 10% meet guidelines when objective assessments of PA are used.26 Thus, there is a need to improve adherence to PA programs using innovative approaches. Economic incentives have been shown to be powerful motivators for behavior change and for improving health outcomes.28-37 While there is evidence suggesting the general efficacy of incentive programs for increasing PA,38 research has not yet demonstrated the optimal format for incentive programs. Nonetheless, spurred by organizational incentives (i.e., tax breaks) provided by the Affordable Health Care Act, major insurance companies are now offering economic incentives for regular attendance at fitness facilities in the absence of empirical support. Thus, we propose to conduct an RCT to examine the efficacy of the exercise incentive program currently offered by three major US insurance companies39-41 consisting of a $200 rebate on fitness facility membership fees for at least 50 confirmed visits to the fitness facility (maximum 1/day, verified by objective swipe-card data) over 6 months. In the context of the RCT, we will also compare the insurance-based standard incentive program to a second, loss-frame incentive condition in which the same incentive schedule is used, but with participants told (and reminded during the course of the program) that $200 of their membership fee is being held and will be returned or forfeited depending on whether they use the gym at least 50 times in the next 6 months. The proposed RCT will be conducted in a community setting at the Greater Providence YMCAs. Aim 1. Conduct an RCT (N=330) comparing (a) the widely used insurance-based Standard incentives program (n=110), (b) a Loss-framed incentive program (n=110), and (c) no-incentive Control (n=110). Each participant will be enrolled for two consecutive 6-month periods for a total of 12 months per participant. The primary outcome will be number of visits to the fitness facility. Secondary outcomes will include total moderate-to-vigorous PA (MVPA) over 7-day periods at 3-month intervals through accelerometers and self-reported MVPA. We hypothesize that the two incentive conditions will result in higher attendance at the YMCA and more PA, with the Loss-framed incentive program outperforming the Standard insurance-based program. Aim 2. Examine habit formation and anticipated regret as putative mediators and household income and age as moderators of the incentive-based programs. Aim 3. Conduct a within trial cost-utility analysis from a societal perspective to quantify (a) the incremental costs per quality-adjusted life year (QALY) gained, (b) cost per change in YMCA attendance, and (c) cost per incremental change in PA. We will additionally apply a productivity model to estimate the economic impact of the intervention on future household and labor force participation.