Commitment Devices, Behavior Change and Population Health

A new addition to the
behavior change tool box

Whenever the Population Health Blog encountered a tobacco user in its clinic, it would gauge the patient's readiness to quit. For those patients who were ready, it then established a future "quit date" (to facilitate planning), a "contract" (a jointly signed prescription for display on the home fridge) and advice to use any money savings (tobacco is expensive) for a nice reward once seven days of success (for example, a restaurant dinner) was achieved.

The PHB didn't know it at the time, but that seven-day reward was a variation of a "commitment device."  That's what it learned after reading this just-published JAMA manuscript by Todd Rogers and colleagues.

Commitment devices are a way that "present" persons can commit their "future selves" to a sufficient level of needed behavior change.  The threat of a penalty, such as the loss of a night out on the town, imposes a limit on future choices and makes success more likely. 

Other examples of commitment devices described by the authors include applying cash to a success contract (for example, employers could link a bonus to participation in a exercise program that would otherwise be lost), "temptation" bundling that limits access to a gratifying experience in exchange for "consistent" behaviors (used with repeated success by the crafty PHB spouse), limiting bad choices to small packages (smaller portion sizes) and partnering (to avoid disappointing a buddy who shares the commitment).

In retrospect, "commitment devices" have been used in population health for decades.  As Rogers et al point out, however, despite some good research on how effective this approach is, they're generally underused by providers and patients.  One potential way to overcome that is to offer them routinely on an "opt-out" basis, 401k savings-plan style.  The authors also point out that a series of commitment devices on a longitudinal basis could be used to blunt drop outs and maintain long-term behavior change. Last but not least, leveraging social networks with or without handheld "apps" remains an area ripe for future research.

As medical homes spread and shared-risk payment reforms gain traction, the art and science of commitment devices will likely grow. Not only is it a cool piece of insider jargon ("Hey, Mary, I like this care management proposal, but have you any plans to develop commitment devices?"), but any addition to the behavior-change tool box can only help.

Image from Wikipedia