Fairness and wellness incentives: what is the relevance of the process-outcome distinction?

Abstract

Objective: To determine whether the commonly drawn distinction between the fairness of incentives targeting behavioral processes (or effort) and those targeting outcomes (or achievement) provide suitable grounds for favoring either approach in healthcare research, policy and practice.

Methods: Conceptual analysis, literature review.

Results: A categorical distinction between process- and outcome-based incentives is less crisp than it seems. Both processes and outcomes involve targets, and both are subject to differences - across and within socio-economic groups - in circumstance and perspective. Thus, a spectrum view is more appropriate, in which the fairness of incentive programs increases with the extent of control that people have. The effectiveness of incentives is a further relevant consideration, and some available evidence suggests that incentives closer to the outcome-end of the spectrum can be more effective.

Conclusions: Simple distinctions between processes and outcomes by themselves provide little assurance that programs are effective or fair. Effectiveness can and should be assessed empirically. Assessments of fairness should focus on the extent to which an activity or outcome might be feasible and under an individual's control, not on whether it targets a process or outcome. Rigid uniform targets for all are generally less desirable than those that reward person-specific improvement.