Stockholm experimented with rewarding compliance while punishing free-riders: if you drove at or under the speed limit, you would be entered into a lottery where the prize fund came from fines that speeders paid. The so-called speed camera lottery is the perfect solution for facilitating behavior change on the roads. But could social gamification improve healthy living and make healthcare systems more sustainable?

The Fun Theory Put In Practice

Kevin Richardson entered into Volkswagen’s The Fun Theory competition in 2010 with his idea about the speed camera lottery. The concept was so powerful that a year later, Stockholm put it to the test temporarily. When your car passed by a specific crossing, a camera snapped a photo of it and measured its speed. If the driver was above the speed limit, a fine was imposed. However, the money was used to enrich a unique fund – the lottery prize for obedient drivers. If you were not a speeder, you could participate in the lottery, and you had the chance to win some money from those who didn’t follow traffic rules.

It’s simple and brilliant. Sticks and carrots on an entirely new level. It punishes free-riders and rewards behavior benefiting the entire community through a fun game. No wonder that Sweden was eager to put the idea to the test. In the trial case, 24,857 cars passed the cameras, and the average speed limit was reduced from 32 km/h to 25 km/h.

How would you imagine the concept in healthcare?

Politico’s eHealth site chose the message I tweeted a few days ago the eHealth tweet of the day contemplating about speed lottery and its potential place in healthcare. What if a nudge towards healthy lifestyle would mean rewarding the right steps and punishing unhealthy choices?

The idea generated a heated discussion: many expressed their frustration about the possibility of punishing unhealthy lifestyles, many pointed to the question whether lifestyles are a result of choice or circumstances; and how would you draw a line to decide who is “under the limit”. What could be done with addictive substances such as smoking or alcohol?

These are all relevant and thoughtful issues which need careful consideration. However, the basic idea is to draw up a system which rewards healthy lifestyle choices and makes unhealthy living less desirable in a certain way. The latter results, in fact, in severe and lethal illnesses and costs healthcare systems billions of dollars. So, while I beware of using punishments, there must be a way of making healthcare more sustainable.

The cost of unhealthy living

While it is difficult to measure health and disease in numbers, as they affect the given person as well as the entire community, there are powerful statistics estimating material costs to healthcare systems caused by consequences of unhealthy living.

For example, look at smoking. Researchers at the World Health Organization (WHO) and the American Cancer Society found that in 2012, the world spent about $422 billion on health care expenses attributable to smoking. Moreover, healthcare costs are only part of the picture. When healthcare expenses are combined with productivity losses due to illnesses, the total economic impact was $1.436 trillion in 2012. That equals about 1.8% of the world’s annual gross domestic product (GDP). Another study from 2016 detailed that in spite of the steady decline of the prevalence of smoking in the US, the total economic cost of the addiction in the US is estimated at more than $300 billion a year. However, a 10% relative reduction in smoking prevalence between a state and the national average in one year was followed by an average $6.3 billion reduction in healthcare expenditure the following year!

Although the study has its limitations, and we are only looking at smoking, while alcohol, drug abuse or laziness have similar adverse effects on the sustainability of healthcare; it shows the impact that a positive change could cause in terms of benefits for an entire society.

The question is how could we arrive at this transformation? What if we follow the laissez-faire principle and let people completely freely decide whether or not they want to take care of their own health? How do we arrive at a fair healthcare system where members of the community who are living healthily and visit the doctor fewer times do not have to pay extra for people with bad habits causing illnesses? What if we used specific rewards or punishments for a gentle push in the direction of healthy lifestyles and indirectly to sustainable healthcare systems? And what if we let technology lead healthcare on a more sustainable path?

Healthcare and the tragedy of the commons

The well-known game theoretical dilemma shows the conflict of self-interest and the common good. Imagine there is a meadow for a community of ten farmers. Everyone has one cow and lets it graze on the beautiful green field. One farmer decides to put two cows on the area so that he can have more milk and more meat. Everyone else follows his example as everyone wants to have more resources. In the end, the meadow runs out of grass as it cannot fill so many bellies.

Although that’s the parable for the need of regulations, the parallel fits the problem of unsustainability of healthcare running into conflict with individual choices.

Nevertheless, what if we still chose the laissez-faire and let people live without any influence on their choices when it comes to lifestyle. Some would argue that humans are rational beings so if they know that something does harm to their bodies, they will change their behavior in the long run without intervention. The effects may take decades or even generations, but change might come naturally.

For example, Goldman Sachs found in their research about millennials that they have a different attitude towards health than previous generations. Attitudes towards smoking or (in a less visible extent but also in the case of) drinking changed in the last decades. 69 percent of 12^th graders disapproved in 1998 if an adult smoked one or more packs of cigarettes a day. In 2013, this percentage increased to 83 percent. It is generally visible that they are exercising more, eating smarter and smoking less than the previous generations.

However, it might not be enough or fast enough for creating sustainable healthcare systems. Without technology and some “nudge” towards a healthy lifestyle, the next or the over next generation coming after millennials might arrive at living a completely healthy lifestyle in the future on average, but that might happen too late. It might come out of necessity –healthcare systems will go bankrupt by that time following the current trajectory.

Healthcare with its sticks and carrots

Imagine a scenario where you would be rewarded for living a healthy life while somehow punished if not doing so – all the while considering your own environment, your own personality, your own goals. What if insurance companies motivated people to stay healthy with health technologies indirectly making healthcare more sustainable?

Oscar Health has already done that in the US. Their patients get Amazon gift cards as rewards for achieving their daily goals as measured by a Fitbit activity tracker. However, much more could be done, as data about sleep quality, physical activity, stress and blood pressure is pouring on companies like rain. Could that data be used for nudging people to live healthier lives? If the answer is yes, how would you avoid the dystopian scenario where choosing a big steak instead of something more suitable for your customized diet or being too lazy to exercise would mean higher insurance premiums?

Imagine that insurance companies can access the data coming from patients’ devices, and they can offer more personalized therapies and plans based on the data. They can reward those people who live a truly healthy life, although people who choose to keep on smoking and not doing exercise supported by an unhealthy diet, would have to pay more to contribute equally to healthcare costs. This way, living an unhealthy life would remain a personal right, but it would also become a luxury to balance out the huge costs they add to the healthcare system. Sounds manageable and fair, right? However, who decides the meaning and “standards” of a healthy lifestyle? What would happen to personal freedom in this scenario?

Let technology take good care of it?

For 2017, total wearable device shipments reached 115.4 million units, up 10.3% from the 104.6 million units shipped in 2016. It is predicted that 245 million wearable devices will be purchased in 2019. And this is just the beginning. Digital tattoos might measure data and notify the user when medical supervision is needed without the user’s active participation. Smart algorithms might browse patients’ health data to discover new correlations and long-term consequences. They might build predictive personal paths based on collected health data for several years ahead. So, what if we let technologies build solutions for making healthcare more sustainable instead of us?

Data analytics, health sensors, wearables, narrow artificial intelligence – digital health tools will gather actively and passively so much data about patients and communities that decision-makers might feel the need to base lifestyle choices and the reorganization of healthcare systems entirely on the power of that data. Neutral, objective, quantitative information would mean the basis for recommendations on healthy living. What if algorithms reducing lifestyle questions to simple computational problems told you how to live and how to live well? Would that be the right path to go down for the future?

While The Medical Futurist believes that healthcare could benefit from some form of social gamification, the devil is in the details. We must somehow find the balance between the common good as well as personal freedom to avoid unsustainability of healthcare on the long run all the while keeping people out of a “health-authoritarian” society powered by technologies. How should we do that? The Swedish speed lottery flashed a particular example. Any other ideas out there?

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