What Health Care Can Learn from a 200 Year Old Economics Lesson

Say you were in a different line of work – the prisoner relocation industry, for instance, and the year was 1790…what’s your most significant business challenge?  Well, if you were doing business out of England, transporting your cargo to Australia without killing them would likely be right up there.
Finding themselves with a homeland prison system bursting at the English seams in the 18^th century, the British government began hiring ship captains to transport masses of prisoners to Australian penitentiaries.  Unfortunately, rough seas of the crossing and ineffective nutrition and medical care along the way took a fatal toll on the individuals being transported – 30% mortality rates per crossing not uncommon.
Over time, the toll also cost the British government.  Yes, these were prisoners, but the public and church railed against the government’s morality failing in allowing the ongoing carnage – the government soon embroiled in scandal.
The British government responded with a host of new rules for prisoner transport – the requirement of medical care practitioners and onboard inspections, lemons to prevent scurvy, raising captains’ salaries, etc.  And although these reforms came with incentives for the captains, they weren’t aligned effectively with the sought-after result – captains finding more reward in selling the government-issued supplemental food at port rather than giving it to the prisoners to keep them alive.  The prisoner shipping program was costing the government even more money, and the high mortality rates continued.
But enter a smart economist of the time who proposed a better idea, and everything changed.  What was it?  Pretty simple really – only pay the sea captains for each prisoner that walked off the ship alive in Australia (not for how many boarded in England).
Fairly immediately, survival rates shot up to 99%.
What’s the parallel lesson for today’s health behavior dilemma?  If we want to truly motivate real and lasting healthy behavior change, incentives must be directly aligned with the outcome we want to achieve.  The fierce tides of maintaining health and wellness can be foreboding and challenging.  But solutions that focus more on the journey, less on the desired outcome risk missing the harbor completely.  Incenting individuals to complete health assessments and screenings is a first step – it begins the engagement process.  But participants need to also be incented to follow through on healthy actions.
Beyond engagement, incenting individuals for health improvement follow-through and results is a game changer in the rough seas (and high stakes) of health improvement.  Isn’t it time we cross the ocean?