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Journal of Medicine and Philosophy, 33: 198– 220, 2008
doi:10.1093/jmp/jhn007
Bonuses as Incentives and Rewards for Health
Responsibility: A Good Thing?
HARALD SCHMIDT
London School of Economics and Political Science, London, UK and Nuffield Council on
Bioethics, London, UK
Bonuses, as incentives or rewards for health-related behavior, fea-
ture prominently in German social health insurance. Their goal is
centered around promoting personal responsibility, but reducing
overall health-care expenditure and enabling competition between
sickness funds also play a role. The central position of personal re-
sponsibility in German health-care policy is described, and a frame-
work is offered for an analysis of the ethical issues raised by policies
seeking to promote responsibility. The framework entails seven tests
relating to: solidarity; equality and equity; intrusiveness; attribut-
ability and opportunity of choice; evidence, rationale, and feasibil-
ity; affected third parties; and coherence. It is contended that a
focus on tests, in particular from within contractualism, is the most
appropriate way of addressing the question of health responsibility in
pluralistic societies. However, taken by themselves, the tests also
allow an identification of the key ethical issues by particular poli-
cies, which are illustrated by applying the framework to particular
bonus polices.
Keywords: bonus, contractualism, equity, german health reform, health
promotion, incentive, prevention, responsibility, solidarity
I. INTRODUCTION
A “bonus” is, broadly, a good thing. In policy and practice, bonuses feature
in arrangements such as linking professional performance to payments over
and above a certain base rate, awarding frequent-flier air miles, or offering
Address correspondence to: Harald Schmidt, LSE Health, LSE, Houghton Street, London, UK,
WC2A 2AE. E-mail: h.t.schmidt@lse.ac.uk.
© The Author 2008. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All
rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org
Bonuses as Incentives and Rewards for Health Responsibility 199
reward cards for supermarket shoppers. In Germany, sickness funds provid-
ing statutory health insurance have offered a range of bonuses, for a range of
health-related behaviors, since 2004 (Braun et al., 2006; Knaack, 2008).
The available bonus schemes have different goals, and there are several
reasons behind their introduction. They are focused centrally, first, around the
moral concept of personal responsibility for health. Closely linked to the con-
cept of solidarity, responsibility plays a prominent role in the German health-
care system, and bonuses are viewed as a way of incentivizing and rewarding
responsible behavior. Second, as for many other publicly funded health-care
systems, the economic strain imposed by “lifestyle diseases” such as obesity
and other chronic conditions are of increasing concern, and, in a more instru-
mental sense, bonuses are viewed as one (of several) practical means of im-
proving active participation in primary and secondary prevention and reducing
cost. Third, the opening of the German insurance market to private providers in
1994 has resulted in increased adoption of market mechanisms by public
providers, with the hope of thereby increasing overall efficiency. A range of
measures has been introduced to improve competition between sickness
funds, and practically all the major insurers offer bonus systems, fully aware of
their marketing potential in terms of attracting and retaining customers.
Ideally, bonus policies help to achieve all the above goals to the benefit of
everyone, disadvantaging no one. However, it is not clear that this is al- ways
the case. Moreover, I will argue, it is also not straightforward to identify which
(set) of the goals exactly is sought to be achieved by particular bonus
programs, and whether they can always be viewed as compatible with
the ethical values underlying public health-care systems in general and the
German system in particular.
Below, I will analyze key features of recent German bonus systems. In the
first section I will provide a brief background to the role of personal respon-
sibility in German health-care law. The second section sets out a framework
for analysis of health responsibilities. In the last section, this framework
is used to evaluate particular legal and policy provisions that relate to bonus
systems aimed at encouraging different notions of health responsibility.
It should be clarified at this stage that in using the term bonus nothing is
implied about the acceptability of the method or about the precise method of its
functioning. Bonuses may work as an incentive in the sense that they are the
sole reason why a person adopts a certain behavior, raising possible issues
about undue inducements. Or they may merely “nudge” people to do
something they intended to do but did not for lack of general motivation. Or
they may constitute a spare wheel, a redundant “extra,” as the fact that a bo-
nus was available actually had no effect on the behavior that entitled people to
a bonus. In principle, the means for bonus payments may be raised
through cross-financing (by other insurance holders) or perhaps by sharing a
proportion of savings that are made because some kind of treatment is not
required as a consequence of behavior change.
200 Harald Schmidt
The concept of health responsibilities, in the following, is understood
as referring to obligations that, for a range of reasons, healthy people, patients,
and the reconvalescent may be said to have toward themselves (in the broad-
est sense: “lead a healthy life”), toward others (“promote and do not damage
the health of others”), or toward a health-care system (“contribute to its equi-
table and efficient operation” [Resnik, 2005, Schmidt, 2007b, English, 2005]).
II. SOLIDARITY AND HEALTH RESPONSIBILITY— THE
GENERAL LEGAL CONTEXT
Book V of the German Social Security Code (Sozialgesetzbuch—SGB)
regulates the provision of statutory health care. Its norms are binding for all
sickness funds providing care for approximately 90% of the German
population (the remainder being covered by private insurance). Article 1 of
SGB V has overarching function and is entitled “Solidarity and personal
responsibility.” A characterization of both concepts is provided in the wording
of Article 1 that reads:
In the spirit of a mutually supportive community [Solidargemeinschaft] the task
of the statutory health insurance is to maintain, restore or improve health of the
insured. The insured have co-responsibility for their health; through a health-
conscious way of living, taking part in appropriately timed preventative measures
[and] playing an active role in treatment and rehabilitation, they should contribute to
avoiding illness and disability, and overcoming the respective consequences. The
statutory sickness funds are to assist the insured persons through the provision
of information, advice and services, and should encourage a health-conscious way of
living [my translation].
The principal characterization of solidarity and personal responsibility is that
the community as a collective, and people individually, are co-“producers” of
health. The notion of co-responsibility has two important facets in this re-
spect. First, it states that the “mutually supportive community” has a certain
degree of responsibility for the health of each individual. In this sense, indi-
viduals are entitled to claims against the community for assistance. Second,
it also implies that the community has certain claims against individuals.
Leaving prudential benefits aside, the appeal to staying healthy has the aim
of containing overall expenditure and opportunity costs. For all care needs
to be financed by the solidaristic community, and limiting ones demands on
the healthcare system reduces expenditure. Using services unnecessarily
may also deprive another person in need of resources or medical attention,
exacerbating resource allocation dilemmas.
Article 2 SGB V on “necessity, cost-effectiveness, and personal responsibil-
ity” is unequivocal in stressing people’s obligations in this respect:
Services … are to be provided by the sickness funds with due respect to cost ef-
fectiveness [Wirtschaftlichkeitsgebot] … and
insofar as the need for services is not
attributable to the personal responsibility of the insured person.
[…] Sickness funds,
Bonuses as Incentives and Rewards for Health Responsibility 201
service providers and insured persons must seek to ensure the clinical and cost-
effectiveness of services,
which are only to be used insofar as necessary [emphasis
added, my translation]
.
Article 2 raises the question of what exactly, in practice, the respective scope
and limitation of solidaristic and personal responsibility should be. Is there a
“worst-case” scenario in which solidaristic coverage would be refused?
Article 52 SGB V sets out conditions under which statutory sickness funds
may limit funding for services, and the most recent health-care reforms of
2007 included a noteworthy specification in this respect. In its pre-2007 ver-
sion, Article 52 stated that insurers may demand a reasonable contribution to
the costs of treatment, if a person’s need for health care is the result of engag-
ing in a criminal activity. Under the 2007 amendments, this principle has been
extended to state that insurers may ask for equivalent contributions where
people request treatment for complications arising from “cosmetic surgery,
tattoos … piercings,” or another “non-medically indicated” measure.
Solidarity and personal responsibility in the old version of Article 52 were
interpreted in such a way that whoever harms the solidaristic community has
lost the claim to having health care needs met at their exclusive expense. In
such cases, financing health care can become a matter of personal responsi-
bility. However, this responsibility extends to the
costs only: for solidarity still
clearly requires the criminal person to be
treated by the health-care services.
The new extension regarding, not criminal action, but nonmedically indi-
cated measures, is far more problematic.
In the following, I will not focus on an analysis of these extreme cases.
However, their review can help identify the principal questions we need to
ask when we try to decide about the acceptability of appeals to responsibil-
ity. I suggest that to evaluate such provisions, as well as, in fact,
any health
responsibility–related policy, including bonus programes, the most helpful
approach is to carry out a number of “tests” that concern the impact of the
respective policy on key normative and structural values and components
integral to a public health-care system. These tests concern solidarity; equal-
ity and equity; intrusiveness; attributability and opportunity of choice; evi-
dence, rationale, and feasibility; affected third parties; and coherence.
III. A FRAMEWORK FOR EVALUATING HEALTH RESPONSIBILITIES
This proposal clearly raises at least two questions: First, why the talk about
tests and not ethical principles or a particular branch of moral theory? Sec-
ond, why these tests, and what exactly do they involve?
At one level, deciding about an appropriate concept of health responsibil-
ity might simply be a matter of choosing the right set of principles or theoreti-
cal framework. For example, Hans Martin Sass has called for a triad of
“responsibility, solidarity, and subsidiarity,” viewing in particular the principle
202 Harald Schmidt
of solidarity as “deeply rooted in European culture and supported by secular
… and Christian ethical positions” (Sass, 1995, 587). Within political philoso-
phy, responsibility features prominently in luck egalitarianism,
1
but also in
communitarian
2
and libertarian,
3
accounts. And the responsibility debate is of
course also closely aligned with particular political positions. The left gener-
ally argues that the focus on the individual is misguided and that it is the en-
vironment and general living conditions that require change for people to be
healthy. The right focuses more strongly on individual behavior and notions
of desert, coupling entitlements to health and other social care more closely
to responsibilities (Schmidt, 2007a).
So in one sense, the question of health responsibilities might simply be a
matter of choosing “the right” normative framework. However, there are two
principal problems with this approach. First, in value pluralistic societies,
agreement about what constitutes the right framework remains generally
elusive. Second, even if we suppose that we are able to find a country in
which all residents (or just citizens) can agree on a single monolithic theory
or accept a set of principles such as Sass’ triad, such value systems are typi-
cally of a very general nature and may not tell us
more geometrico how to
decide particular cases, or, in the present context, judge concrete policies.
The approach proposed here, focusing on addressing questions around
health responsibility with a number of tests, by contrast, has several advan-
tages, and can be used in three different ways.
First, the tests specify clearly the areas in which justification is required. In
one sense, they might be understood to be complementary to the aforemen-
tioned normative frameworks, within which subsequent justification in each
particular area may be provided. On this view, the tests may be seen as a nec-
essary, although not sufficient, condition of relating abstract theory to specific
policy proposals and making sense of the meaning of health responsibility.
Alternatively, the “fact of pluralism,” characterizing modern liberal societ-
ies, might be taken more seriously, and the focus on particular normative
frameworks for justification may be relegated to the background. Accord-
ingly, setting out a range of tests can be useful, if not constitutive, in a more
policy-orientated approach that focuses on “accountability for reasonable-
ness,” as set out by Norman Daniels and James Sabin (Daniels, 2000). Here,
the idea that a universally accepted notion of personal responsibility can be
realized in pluralistic societies is abandoned, but the argument might be
made that as long as policies fulfill four conditions (relating to publicity, rel-
evance, revision and appeals, and regulation) and as long as explicit justifi-
cation in each of the areas specified by the tests is provided, reasonable
policy has been secured (Schmidt, forthcoming).
Lastly, the fact of pluralism and the normative value of justification may be
acknowledged by using the tests within a contractualist framework, as pre-
sented, for example, by contemporary proponents such as Thomas Scanlon.
Although, for space and other reasons, I shall not pursue this general project
Bonuses as Incentives and Rewards for Health Responsibility 203
here, I contend that this is in fact the most promising strategy, not least be-
cause of Scanlon’s discussion around responsibility. I will return to his useful
distinction between
responsibility as attributability and substantive responsi-
bility below, and I will assume in the following that it makes sense to use
the tests sketched out here in a project that focuses on identifying those
principles or policies that, provided people have certain choices, “no-one
could reasonably reject” (Scanlon, 1998, 153). The corollary is that such
norms have particular robustness and in fact special moral value. However,
even if the reader is not inclined to make this leap at this stage, it will be-
come clear that the proposed framework is well suited to interrogate the
German policy on health-care bonuses as set out in SGB V and provide help-
ful illumination of significant ethical tensions.
The seven tests proposed here are not intended as an exhaustive list.
However, they are informed by an analysis of the kinds of issues raised by
legal and policy provisions found in major patient charters and similar docu-
ments
4
and by the range of arguments typically set forth by proponents and
opponents of health responsibility.
5
Solidarity Test
Health as a good is special in at least two ways: first, in a very obvious sense,
good health matters in our lives in experiential, if not existential terms. Sec-
ond, health has a clear impact on one’s civic and economic livelihood and
the options one can make use of in a society based on fair equality of op-
portunity (Daniels, 2007). On an individual basis, regaining health in the
case of sickness can be extremely costly, if not impossible to afford. Admit-
tedly, countries that have made social health insurance mandatory have
taken away a degree of liberty in relation to whether or not people should
protect themselves against the consequences of poor health. But nonethe-
less, it is plausible to describe those brought together in social health insur-
ance systems as being in a solidaristic relationship with others, which has the
aim of providing mutual protection against the negative implication of
diseases.
In the German law, solidarity is, as discussed briefly above, linked closely to
the concept of personal responsibility. Further, solidarity is addressed in relation
to the financing of health care. Employers and employees split contributions,
each paying 6%–8% of the employee’s gross salary. Contributions are not taxed
and are capped at an annual gross salary of currently €46,350. There is no indi-
vidual or sex-specific risk assessment, and contributions and expenditures are
generally pooled. Therefore, solidarity means, first, that those who are able to
work, especially healthy and young people, support the less healthy, unem-
ployed, and older (or retired) individuals as they contribute more and generally
use less resources. Second, due to means-tested contributions, the more well-
off support the less well-off. Third, those without families support those with
204 Harald Schmidt
dependents, as partners and children are insured at no extra cost through the
main insurance contributor (the person working and paying insurance
contributions).
In addition to the more strategic characterization of solidarity above,
where, under a form of fair reciprocity, equals join up for mutual benefit,
this sketch of the German financing system also reveals a different notion of
solidarity: inbuilt in its focus on extending coverage to people in especially
vulnerable situations is a notion of solidarity as “giving-without-expectation-
of-return.” The general concept of solidarity is highly complex. In addition
to the two notions introduced here, recent work examining its motivation,
function, and role in different European health-care systems has analyzed it
among other things, as attitudes of individuals or descriptions of communal
arrangements, and has explored notions of fellowship, compassion, charity,
altruism, universal or group-specific brotherhood, friendship, interest coali-
tions, civic duties, or mutual recognition and interdependency of individuals
(Houtepen and Meulen, 2000a).
Although there are hence a range of different candidates that might ex-
plain why solidarity should matter, it is clear that a functional baseline de-
scription of solidarity in public health-care systems would be focused around
the notion of achieving collectively a degree of security that could not gener-
ally be achieved individually. In this sense, solidarity has also been charac-
terized as “the ‘beating heart’ of a social health insurance approach” (Saltman,
2004, 29).
6
It is equally clear, then, that any evaluation of appeals to health
responsibilities, whether in the form of bonus systems or policies that have
a more negative character, needs to consider whether they are likely to en-
hance this central concept or will be to its detriment.
Equity and Equality Test
Broadly speaking, inequalities relate to the uneven distribution of goods
(or access to them), and such distributions are inequitable when they are
unfair or unjust. In one sense, one could assume that assessing a policy in
terms of its impact on solidarity is the same as assessing it in terms of its
impact on equality and equity. However, this is not necessarily the case, as
there can be arrangements that satisfy a particular concept of solidarity, al-
though they may not treat everyone equally and/or equitably. For exam-
ple, although a system might be described as solidaristic in view of the
mechanisms of financing and access to health services, other organiza-
tional arrangements or societal factors may mean that some groups of
people benefit more than others. Given that the reduction of inequalities
in health and social status through largely prioritarian strategies is an ex-
plicit goal of all liberal European states, it is therefore useful to assess
whether particular responsibilities are likely to contribute to reducing in-
equalities or not.
Bonuses as Incentives and Rewards for Health Responsibility 205
Intrusiveness Test
Promoting personal responsibility is often seen as synonymous with impos-
ing highly intrusive and paternalistic measures. However, this is far from
necessary, and the means available include mere provision of information or
nondirective education, targeted and directive education and persuasion; the
use of financial and other incentives and disincentives, possibly targeted at
different populations (taxes, different levels of insurance contribution or co-
payments, bonuses, etc.); restricting access to particular interventions; and
ultimately infringing civil liberties (such as mandatory isolation of people
with highly infectious diseases who refuse to accept the responsibility not to
harm others). (Nuffield Council on Bioethics, 2007)
Minimizing intrusion is not only of relevance in terms of respect for au-
tonomy but also with regard to the acceptability and sustainability of a pro-
gram seeking to promote responsibility. The intrusiveness test therefore
concerns the extent of interference and in a wider assessment whether a
particular measure is likely to be the least intrusive, but most effective of a
set of available options.
Attributability and Opportunities of Choice Test
One of the most controversial issues in the debate about health responsibili-
ties concerns the question of how to consider, in praising or blaming, or
making decisions about access to health care, the extent to which people’s
behavior contributed to a good or bad health outcome. Controversy sur-
rounds, in particular, the discussion around negative health outcomes and
their association with blame and reduced access to health care.
For some, the question of holding people responsible or imposing sanc-
tions is the same as assessing the extent to which an action is attributable,
as, for example, also suggested verbatim in the above quote from Article 2
SGB V. However, attributability can admit of degrees, and the question might
then turn on what degree or threshold of attributability should be sufficient.
This is particularly relevant in considering responsibility in the health-care
context. For, clearly, disease development is affected by a highly complex
range of factors that include genetic predispositions, biological processes,
and environmental conditions, in addition to behavior. It would amount to a
Kafkaesque situation to say someone has only themselves to blame for a
health outcome and has lost all claims to assistance if the actual causal fac-
tors were in fact fully, or to a significant extent, outside of that person’s con-
trol. One option, therefore, is to abandon any talk about apportioning
responsibility for bad health outcomes.
Another is to analyze more closely the kinds of responsibilities involved.
Scanlon distinguishes two principal types.
Responsibility as attributability
concerns our assessments relating to praise and blame and rests on whether
a given action is attributable in the sense that the choices were guided by
206 Harald Schmidt
the attitudes of the person who is judged (Scanlon, 1998, 290). Hence, we
might acknowledge that in the case of some people, their behavior played
a certain causal role in contributing to a disease but not feel it appropriate
to blame them for it. There may be others, however, where we might want to
do so, provided their behavior was guided by their attitudes. And equally
we might praise people in cases where their attitudes led to behavior that
produced a good health state. However, adapting Scanlon’s model, none of
these assessments determine what people are owed. Such obligations rest
on
substantive responsibility, which can be independent of the choices a
person has made. On this view, what a person is owed is determined pri-
marily, if not exclusively, by the opportunities a person had for making the
right choices: “what matters is the value of the opportunity to choose that
the person is presented with. If a person has been placed in a sufficiently good
position, this can make it the case that he or she has no valid com-
plaint about what results, whether or not it is produced by his or her active
choice” (Scanlon, 1998, 258). In deciding what kind of opportunities need
to be provided in this respect, Scanlon suggests that we should be guided
by reasons “that people in general have reason to value,” as “the justifiability
of a moral principle must rest on [generic reasons]” (Scanlon, 1998, 263,
cf205) people have in a given situation and not on their particular values
and attitudes.
For the evaluation of particular polices, it then follows that a close assess-
ment is required of the kinds of opportunities that they create and how they
relate to the general opportunities that people have in their lives. People’s
claims against the solidaristic community may only be lessened if the poli-
cies have provided them with option sets that allow people motivated by
generic reasons to prevent harm. In a positive sense, substantive responsibil-
ity may justify offering rewards for positive behavior. And independently of
the question of substantive responsibility, the notion of attributive responsi-
bility may still allow us to praise or blame people’s behavior, or to appeal to
them to change their behavior where we judge they should behave differ-
ently and it is in their power to do so. But the latter judgments are distinct from
decisions about what people are owed.
Evidence and Rationale, Feasibility Test
As obvious from the brief discussion around Article 1 SGB, in view of possi-
ble opportunity costs, personal responsibility can be emphasized on the
grounds of fairness toward others in the solidaristic community. Or it may be
based on a more general appeal to efficient use of health-care resources. In any
case, evidence is required that a particular policy and means used to en- force it
will actually help realize the justificatory reasons. Being explicit about
evidence and underlying rationales is crucial in justifying and securing support
for particular health responsibility policies, and to avoid “legal moralism”
Bonuses as Incentives and Rewards for Health Responsibility 207
(Wikler, 1978, 316, 332), where particular behaviors are rewarded or penal-
ized simply because those setting policy have a like or dislike for them. An
assessment of the rationale may also help us to understand better the primary
beneficiaries of particular polices, who may not always be individual people,
or the solidaristic community, but perhaps (also) insurance providers or gov-
ernment departments receiving taxes.
In considering different policy options, an assessment is furthermore re-
quired of the administrative and general organizational effort necessary to
set out health responsibilities, and, where deemed appropriate, to enforce
them. It may be that although some types of responsibility can be clearly
specified, and are reasonable, their enforcement would simply be dispropor-
tionate in terms of cost or effort.
Affected Third Parties Test
The implementation of responsibilities set out in law or policy also needs to
consider the effect on third parties. Doctors may (or may not) wish to appeal
to patients’ responsibilities to change their behavior. However, depending
on the type of responsibility, doctors may also be required to pass on infor-
mation to sickness funds or similar agencies about whether or not people
comply with particular obligations. This may affect the doctor-patient rela-
tionship, as it may give an unwelcome policing function to health-care pro-
fessionals or may have a negative impact on people’s willingness to come
into contact with health services. The implications of particular responsibili-
ties for the various agents involved and the relationships between them,
therefore, also require close scrutiny.
Coherence Test
Justice, in one meaning, demands treating similar cases similarly. Particular
forms of health responsibility therefore need to be compared to other health
responsibilities and to obligations in social policy more widely.
A comparison to other areas of social policy may furthermore be inter-
esting since many of the hard questions in apportioning responsibility
also arise in other contexts, such as criminal, tort, and liability law. For
example, in the United Kingdom and Germany, contributory negligence
(Eigenverschulden) commonly leads to reductions in personal injury
claims brought by victims of traffic accidents who failed to wear a seat belt
(if wearing the seatbelt would have prevented or significantly limited the
harm caused). Of course, such comparisons do not mean that identical
standards need to be implemented in the health context—there may be
morally relevant differences. But ultimately, a coherent use of responsibil-
ity would be the ideal outcome, whether this means similar or distinct
policies.
208 Harald Schmidt
IV. BONUS SYSTEMS IN GERMANY—ANALYSIS
The next section will illustrate the usefulness of the above tests in identifying
different types of ethical “pulls” arising from a range of appeals to responsi-
bility in the German health-care system. Some of the bonus programs dis-
cussed here have an obvious motivation of improving both health of the
person concerned and the efficiency of the health-care system (such as bo-
nuses for participation in primary prevention), whereas others are primarily
cost driven (such as bonuses for no-claims behavior).
Description of Bonus Systems
General primary and secondary prevention
Since 2004, Article 65a SGB V permits providers of statutory health insurance
to offer bonuses for those who take an active part in a range of primary and
secondary prevention measures. One may qualify by taking part in age-
related checkup programs (such as presymptomatic examinations for cardio-
vascular diseases, diabetes, and kidney diseases) or in particular health
maintenance activities that are supported by sickness funds. These may in-
clude attending dieting, smoking cessation, or yoga courses. Some sickness
funds also accept active membership in a sports club as evidence of efforts
to maintain one’s health.
Bonuses may take different forms. One type consists of awarding points
of a nominal value for taking part in certain measures. Once a certain
threshold of points has been reached, they can be redeemed for a range of
items including sports equipment, health books, iPods, or vouchers for mu-
sic downloads. Many providers also offer the option of redeeming the col-
lected points for cash. For example, in the case of one of the biggest
providers, the Techniker Krankenkasse, qualifying measures typically have
a value between €5 and €30 (with an arithmetic mean of €10.48). A four-
person family may redeem between €100 and €200 per year through such
schemes. The Barmer Ersatzkasse allows members to reduce their insurance
contributions. For example, a 45-year-old person living in the western parts of
Germany, with no children, earning €2,500 gross per month can save
6.97% of monthly contributions (or €5.83) by demonstrating that indices
such as body mass index (BMI), blood pressure, blood sugar, and choles-
terol are in an acceptable range over a period of at least 1 year (Schmidt,
2007c).
Secondary prevention: cancer screening
The 2007 reforms introduced a particular incentive program for potential
breast, cervical, and colon cancer patients. Previously, Article 62 SGB V de-
termined that health-care co-payments for chronically ill patients suffering
Bonuses as Incentives and Rewards for Health Responsibility 209
from such and other chronic diseases were capped at a maximum of 1% of
their gross annual income. From January 2008, this has been increased to 2%;
however, people can reduce the co-payment threshold to 1% if, firstly, prior
to becoming sick, they have attended (nondirective) counseling sessions on
the advantages and disadvantages of screenings for each disease no later than
2 years from the qualifying age, and secondly, if in case of a later disease a
doctor issues on an annual basis a certificate confirming that the patient has
adhered to previously agreed treatment plans. Following some controversy it
was agreed that non-compliance would be certified only in those cases where
patients refused treatment (Gemeinsamer Bundesausschuss, 2007).
7
Secondary prevention: dental care
Article 55 and 56 SGB V stipulate that providers of statutory health insurance
must cover 50% of the costs for required dental replacements, with the other
half falling to the insured person. Insurance providers must increase their
contribution by 20% of their initial payment, if, over a period of 5 years,
adults have taken part in annual checkup programs (and under 18 year olds
in biannual ones). If there are no gaps over the past 10 years, this is in-
creased to 30%. However, if there are gaps, the insured persons have to pay
their full 50%.
Bonuses and personalized plans
Under the health reform 2007, implemented by the Gesetz zur Stärkung des
Wettbewerbs in der gesetzlichen Krankenversicherung “Law to strengthen
competition among statutory sickness funds”) Article 53 SGB V has been re-
vised to require all sickness funds to provide five defined “personalized”
plans (Wahltarife) which relate to the participation in special care programs
(including particular schemes recommended by the sickness fund, schemes
that focus on general practitioner (GP)-centered care, and using outpatient
services from an agreed set of providers only). Since these programs are
thought to reduce the burden of morbidity and costs for the insurers, con-
tributions for those taking part in the schemes may be reduced, or lower
co-payments for services may be offered, where such payments are re-
quired. In addition, insurers may offer plans that include “no-claim bo-
nuses,” irrespectively of whether people also make use of one of the
aforementioned programs. Bonuses of up to 20% of the annual insurance
contributions may be awarded, capped, however, at €600 maximum (or
€900, where several different bonus plans are combined). While “no-claim
bonus” schemes differ in their precise conditions between providers, they
generally revolve around limiting the use of prescription drugs and hospi-
talization (in the case of one major provider, no GP appointments for pre-
scription drugs and no hospitalization over a year secures the maximum
bonus) (Schmidt, 2007c).
210 Harald Schmidt
V. DISCUSSION
Evidence, Rationale, and Feasibility
The most general question in considering the evidence, rationale, and feasi-
bility of bonus programs aimed at health promotion probably concerns the
question of whether such measures can in fact help contain overall health-
care expenditure (Cohen et al. 2008, Schauffler 2000).
Clearly, looking after oneself can improve health, reduce health-care
needs, and extend life expectancy. For example, according to the recent
large-scale european prospective investigation into cancer and nutrition
(EPIC)-Norfolk Prospective Population Study, taking up four health behav-
iors (exercise, moderate alcohol, not smoking, and regular fruit and vegeta-
ble intake) can add 14 years of life expectancy (Khaw et al., 2008). But it is
not clear that longer, healthier lives will lead to reduction in cost for the
health care system. Pieter van Baal et al. used a dynamic population model
to analyze health-care data from The Netherlands in order to estimate life-
time health-care cost conditional on the presence of risk factors. They found
that expenditure was highest for the healthy (defined as: non-smoking, BMI
between 18.5 and 25: health care cost from age 20 was estimated to be
€281,000) and lowest for smokers (€220,000), with obese people in an inter-
mediate position (€250,000), largely due to differences in the higher life ex-
pectancy of healthy people, and associated cost for care. However, there is
dispute about whether increasingly higher life expectancy will in fact lead
to higher levels of morbidity and care needs (the “medicalization thesis”
[Wiener, Illston, and Hanley, 1994]) or whether longer life will mean that the
phase of care needed is simply condensed over a shorter time than previ-
ously (the “compression thesis” [Metz, 2001; Kühn, 2005]), with some argu-
ing that this will not lead to overall increases in health-care expenditure
and others less convinced about possible savings (Niehaus, 2006). And ques-
tions about costs would also need to consider whether economic factors
outside of the health-care sector should be considered in the form of health
behavior–associated revenues (such as taxes) and losses (workdays due to
sickness).
This is not the place to analyze in detail complex empirical or modeling
data. However, it is noteworthy that some of the hard questions of distribu-
tive justice around people’s responsibilities may actually turn to a significant
extent on an empirical analysis of actual costs associated with particular risk
factors and ageing populations, which are often simply assumed. Regarding
the possible options of how the cost question might be resolved within the
more narrow focus of health care, it seems that if it should turn out that
healthy living does indeed save health-care expenditure, prudence consider-
ations aside, efficiency and solidarity considerations would make health pro-
motion through bonus systems a legitimate aim in principle. Equally, if there
Bonuses as Incentives and Rewards for Health Responsibility 211
is equipoise, for there would still be the gain in quality of life. By contrast,
in the situation where unhealthy behavior constitutes an economic advan-
tage to sickness funds, the main rationale behind appeals to health behavior
would appear not to rest on distributive justice grounds, but on fairness con-
siderations, relating to avoiding opportunity cost (as care for an overall
“cheaper” smoker, say, would typically still curtail resources that are avail-
able for the treatment of other diseases). Hence, possible negative assess-
ments of people who fail to behave “responsibly” (in the senses implied by
bonus programs that seek to encourage a healthy way of living) would need
to be adjusted accordingly, as, to some extent, the argument can be made
that they have “paid their way,” largely by dying earlier. Equally, the way
such programs are advertised would need to be carried out in a way that
avoided some form of unwarranted health paternalism or risk of stigmatiza-
tion of already vulnerable groups, such as obese people.
A further general question concerns whether bonus systems are the right
tool for the job of improving population health. Following Geoffrey Rose’s
seminal 1985 paper “Sick individuals and sick populations,” the argument
can be made that a focus on consumerist models and “over-dependence on
individual choice will not achieve changes in society norms” (Doyle, Furey,
and Flowers, 2006, 397) and will be to the detriment of the vulnerable and
disadvantaged in society. Instead, broader public health measures should be
promoted. One way of responding to this would be to argue that there is
nothing wrong with a “both/and” approach, focusing on the underlying soci-
etal and other causes of disease as well as offering incentives to people indi-
vidually. However, it is clear that at this point the equity test comes into play.
For if bonus uptake is self-selecting, and consumerist initiatives increase in-
equality, and if it is a declared aim of a health-care system to contribute to
reducing inequalities, it may not be desirable to pursue both strategies.
Without further empirical evidence, it is difficult to decide whether the ra-
tionale of bonus programs of contributing to efficiency and equitable popu-
lation health simultaneously is achievable, or whether, perhaps, their principal
function is that of a marketing tool, helping sickness funds to attract and re-
tain customers. If the latter was the case, health responsibilities implied by
bonus programs might need to be viewed in a very different light. SGB V
stipulates that bonuses must not be funded through higher insurance contri-
butions but through savings that result from people’s improved health. Sick-
ness funds are required to report in 3-yearly intervals on the operation of
bonus programs to the relevant authority (the Bundesversicherungsamt,
BVA), which, at the time of writing, is in the process of completing the
first ever evaluation. Although the demonstration of cost savings over such
a short time frame is nontrivial, early indications seem to suggest that the
programs are in fact self-financing. However, clearly, this question needs
to be considered in more detail in context of the final data of the initial
212 Harald Schmidt
analysis, on a case-by-case basis for each of the programs, and, perhaps more
importantly, also over a longer time frame, in order to assess whether or
not bonus programs have the effect of simply pushing cost forward in time.
In terms of feasibility, it is likely that the analysis by the BVA will also in-
clude an assessment of the administrative and organizational burden entailed
for the sickness funds offering bonus programs. However, it seems improba-
ble that this will have a significant impact on the general question of the
bonus programs sketched above, as the assessments are relatively labor un-
intensive. By contrast, in the case of Article 62 SGB V, concerning counseling
about the potential of cancer screenings, the Gemeinsamer Bundesausschuss
(G-BA), which was tasked with elaborating a guideline for the implementa-
tion of the law, cautioned that there was general absence of evidence that
population-wide screening programs will lead to net savings (Gemeinsamer
Bundesausschuss, 2007). So it remains to be seen whether the cost-
containment rationale that the Government stressed in introducing the
scheme will be feasible. It will depend largely on the extent to which the
new rule will increase the numbers of those undergoing one of the three
screens: if there is a very high uptake the screens may well increase, rather
than decrease, overall expenditure, while not improving quality of life.
Solidarity
On one view it could be argued that bonus schemes have nothing but a pos-
itive effect on solidarity. For they incentivize and reward those who behave
in ways that are assumed to make the health-care system more efficient, and
the premiums are financed through the savings that are made in the process.
As noted above, the truth of the economic element of this assumption de-
pends to some extent on empirical evidence.
However, there is also a more conceptual point to be made. It is not im-
plausible to assume that a sizable proportion of those who are eligible for
bonuses would have behaved in the way that “earned” them the bonus any-
way, simply because they follow a healthy way of living. In the “postbonus”
phase, they therefore act no different than in the “prebonus” phase. Due to
the risk-pooling system inbuilt in the financing of the statutory health insur-
ance, in the prebonus phase they would then have contributed relatively
more than in the postbonus phase, with expenditure remaining constant. In
such cases, the introduction of bonus systems can be seen as eroding the
notion of solidarity as one of “giving-without-expectation-of-return.” More-
over, not only would preexisting inequity allow some to benefit more than
others from bonus systems but the schemes would also exacerbate such in-
equalities. Certainly in the early phase of the introduction of bonus pro-
grams, this was the case: 19%, or almost twice as many people belonging to
the fifth (least poor) quintile, used bonus programs in 2004/2005 as opposed
to 11% of the first (poorest) quintile (Braun et al., 2006).
Bonuses as Incentives and Rewards for Health Responsibility 213
In a lesser sense, solidarity might also be undermined in that the merito-
cratic element in bonuses might not be appreciated equally by all insurance
holders. Those who are not able to mobilize themselves to actions for which
bonuses are provided might envy those who do and find any competitive-
ness at odds with a conception of solidarity that relates to a union of people
who have come together to offer mutual support rather than join in a race
for bonuses. Alternatively, finding that they are not able to perform bonus-
rewarded behavior may result in a feeling of disappointment and perhaps
lessen their self-esteem, sense of belonging to the solidaristic community, or
feeling that their needs are being cared for appropriately.
Either way, it is clear that even if sickness funds should be persuaded that
these risks are sufficient to reconsider offering bonus programs, doing so
might also have a disadvantage. For those people who are most likely to be
interested in bonus programs—the relatively well-off and healthy—may then
be more tempted to seek a private provider instead of a public one. Retaining
them, by contrast, would, at least in the short term, guarantee insurance hold-
ers with lower associated expenditures and comparatively higher contribu-
tions, benefiting, possibly, also poorer members of the solidaristic community.
Equality and Equity
Equity issues are raised in particular by the newly introduced Wahltarife. Al-
though most bonus schemes can be used on a one-off basis, the minimum
membership for all personalized plans is 3 years. It is only in exceptional
circumstances possible to switch during this time. Sickness funds reserve the
right to make adjustments to the level of bonuses or co-payments during this
time, and insured persons may thus find themselves “trapped” in schemes
that eventually turn out to be less attractive. This may have harsh conse-
quences for those who were attracted to the plans because of the option of
possible savings.
Bonus payments are limited to 20% of the annual contributions, but the
schemes might nonetheless lead to a form of “health gambling”: if the insured
persons stay healthy, they may make a gain. However, if they banked on re-
deeming the bonus and end up requiring treatment, they may either be faced
with a financial “loss” of varying degree or, alternatively, may seek to avoid
or delay necessary prescriptions or even a necessary hospitalization. It is also
clear that this aspect is likely to make no-claim tariffs more attractive to some
than to others. Although it might be of interest to the young and healthy, it
will be less interesting to the elderly—unless they are very lucky gamblers.
The law is clear that medical appointments for routine checkups and pre-
ventative measures do not reduce the bonus in the case of no-claim schemes.
However, patients, in particular those from disadvantaged groups of society,
may be unsure about this and there is a risk that they are more reluctant to
take part in these measures. This might jeopardize their health and could
214 Harald Schmidt
also have an effect that is diametrically opposed to the overarching focus on
prevention and cost-containment that guided the most recent reforms.
Lastly, with several dozen major statutory sickness funds, each offering
five defined plans as well as an open-ended number of further personalized
plans, choice has certainly increased. But not all will be able to benefit from
this choice, as people have different capacities and opportunities to ascertain
which plans would be the most appropriate for their needs.
Intrusiveness
Bonus systems generally are not particularly intrusive, as they merely exist
in the form of offers which insurance holders are free to take up. However,
insurers differ in the way they advertise their programs, and it is not uncom-
mon for insurance holders to receive frequent reminders by mail or other
means. Such initiatives may be perceived as “nannying” of forms of “healthism”
and may have a counterproductive effect on health responsibility attitudes.
Of the measures sketched above, those relating to presymptomatic check-
ups and in particular the scheme encouraging people to attend counseling
sessions on cancer screens may also be intrusive in the sense that they bring
uncertain and unwelcome knowledge about disease susceptibility, possibly
leading to anxiety or confusion. The degree of intrusiveness can however be
mitigated by focusing on providing information with suitable confidence in-
tervals and the option for people to discuss any questions they may have.
Attributability and Opportunity of Choice
The majority of bonus systems involves relatively straightforward assess-
ments of health-related behavior: people receive a bonus if they attend age-
related health checkups or smoking cessation classes, go to the gym,
or demonstrate that health relevant data are within a predefined range.
Although the bonuses for the latter type of activity measure behavior in
relation to particular health outcomes, in the majority of cases, rewards are
given for merely anticipated future health outcomes: no evidence is required
that the action for which the bonus was awarded has actually led to better
health. It is simply the participation that is rewarded, and the bonus is not
desert-based, in the sense that it is given irrespective of whether people
would have behaved in the bonus qualifying way anyway or whether they
made an extra effort and actively tried to be healthy.
A more complicated situation is given in the case of the cancer-screening
policy, as “the bonus” of participating in counseling is linked with later
health outcomes. Moreover, it consists not in a reward over and above a
neutral baseline but in a reduction of co-payments from 2% to 1%. It can be
helpful to approach the issue by assuming that in clear contrast to the cur-
rent situation, we are faced with a (future or entirely hypothetical) situation
Bonuses as Incentives and Rewards for Health Responsibility 215
in which cancer screens have a negligible false-positive and false-negative
rate, the cost of screening is low, and the cost of treatment can be reduced
significantly by early detection and treatment. In such a scenario it can make
sense to argue that the opportunity of choice matters, and that, while it
would be wrong to force people to undergo screening, where they do not
make use of it in a reasonable time frame—for whatever reason—the higher
cost for later treatment should not fall exclusively on the solidaristic commu-
nity. However, would this mean that those failing to attend screenings have
lost
any claim for assistance? A strict interpretation of Scanlon’s version of
substantive responsibility could be interpreted as requiring this. However,
such a policy would be at odds with the fundamental principle of solidarity
that is at the heart of social insurance systems, and a solution in the form of
co-payments might be legitimate in such an idealized scenario.
Although advances in technology may increase the accuracy of presymp-
tomatic screens, clearly, the currently available tests vary considerably in terms
of their confidence intervals, depending in particular on the age at which
the screening takes place. Hence, it was right for the G-BA to reject the gov-
ernment’s initial proposal that would have made access to the lowest co-
payment level conditional on undergoing the respective screen (Gemeinsamer
Bundesausschuss, 2007). Firstly, on cost-effectiveness grounds, and secondly,
because it would have imposed an undue psychological burden on those un-
dergoing the screens with the primary aim of limiting possible future
co-payments.
But what should we make of the final G-BA proposal that then became
policy and links lower co-payments with attending counseling about the ad-
vantages of the screens within 2 years of eligibility? I will explore here the
thought that it is acceptable in one way and less so in another. Provided that
counseling is nondirective, that the ultimate decision about whether or not
to undergo the screen is genuinely up to the people concerned, and that
people have been invited by appropriate means and had reasonable oppor-
tunities to attend a counseling session within the required 2 years after be-
coming eligible (which would depend on the availability of counselors in
the region, and at appropriate times, etc.), it is plausible to argue that the
policy can be acceptable. For, the ultimate decision about undergoing
the screen needs to be made by the persons concerned, especially since the
screens are beset by some uncertainty. But few people spend their Saturday
afternoons thinking about whether or not to go for a colon cancer screen,
even if they know they should. Hence, the conditionality can work both as
a mobilizer that can help people develop their judgment on health matters
(becoming “gesundheitsmündig,” as Sass [2006] puts it) and thus has pruden-
tial benefit, as well as permitting potential cost-containment through early
detection and treatment of diseases.
However, it is far less clear whether the financing principle behind
the current policy should be acceptable. The standard cap for annual
216 Harald Schmidt
co-payments for all insured people in statutory sickness funds is 2% of one’s
annual gross income. The option of reducing this to 1% has some attraction.
However, it needs to be seen in the context of the rule for the “ordinary”
chronically ill, who only pay 1% by default. So, the “incentive” or bonus has
simply been created by doubling the base rate—but it could equally have
been implemented as, for example, an option of halving the “standard” 1%
chronically ill co-payment level to a 0.5% rate. It is far from clear how the in-
crease to 2% is justified by reference to the “special personal responsibilit[ies]”
(Bundesregierung, 2006, 305) of some chronically ill people, as suggested by
the government in its justification of the revised law. I am leaving aside here
the question of whether even the 1% threshold is—actuarially or otherwise—
warranted, but the primary point is that it is more than odd to create bonus-
options for some patient groups by increasing the base level that is generally
thought to be appropriate for the group as a whole. It is moreover unfair, as
it disadvantages those eventually suffering from one of the three cancers,
who, arguably, are as much chronically ill as those suffering other diseases.
Affected Third Parties
For the most part, the administration of bonus programs does not involve
third parties, as the insured generally report their qualifying behavior directly
to the sickness fund. In the case of dentist visits, reception staff may log the
dates electronically, and the determination of other types of bonus qualify-
ing behavior may involve health-care staff, for example, they are required
where rewards are made if key health data such as blood pressure, etc. stays
within a certain range over a year. Those on no-claim plans may wish that
health care staff was not involved, if they require treatment before comple-
tion of the qualifying period, and issues may arise where patients appeal to
staff not to record their appointment. Most of these situations are, however,
likely to just lead to awkward situations. A more problematic situation can
be given in the case of the above-mentioned cancer-screening program:
conflicting goals may arise for health-care professionals in the sense that
counseling is to be offered by medical professionals who are also qualified
to carry out the respective screens. While, clearly, this can be a good thing, it
may pose problems where counselors are overly enthusiastic about the
technology. The potentially most problematic implications arise from the re-
quirement of making the lowest co-payment threshold conditional on an
annual certificate that confirms compliance, which may put the doctor in an
actual, or perceived, policing position and may hence have a detrimental ef-
fect on the doctor-patient relationship.
Coherence
The coherence test is more relevant for cases where sanctions for contribu-
tions to a bad health outcome are contemplated. In the case of bonuses, a
Bonuses as Incentives and Rewards for Health Responsibility 217
comparison to other policies, such as reward cards in shops, or car insurance,
emphasizes again the consumerist, market-driven element of such policies.
VI. CONCLUSION
The framework presented here has shown that bonus systems give rise to dif-
ferent kinds of ethical tensions. Although, in principle, a market-based ap-
proach need not be incompatible with the values underlying social health
insurance, the consumerist concept inbuilt in bonus programs has worrying
implications for equity and solidarity. Bonus payments relying on self-selection
have a clear tendency to negatively affect the risk-pooling principle and to re-
duce the funds available to the solidaristic collective. The benefits are in practice
unlikely to be available to all. In particular, those who are already in disadvan-
taged or vulnerable positions stand to gain far less. In this sense, bonus sys-
tems betray their name and are not as good a thing as the label suggests.
In terms of promoting responsibility, bonuses can be said to achieve little
where they are awarded for behavior that people would have displayed any-
way (whether because they were sufficiently self-motivated or just had the
right habit). It was shown that a program seeking to incentivize people to
contribute to overall efficiency by attending counseling sessions on cancer
screens could be seen as appealing to a legitimate sense of substantive respon-
sibility, in principle. However, its implementation which rested on the option
of reducing co-payments from 2% to the general level for all other chronically
ill of 1% in the case of suffering a screening-related disease was unjustified.
Nonetheless, it would be premature to conclude that bonus systems should
be abandoned. As noted, the first ever-economic evaluation of the overall
effectiveness of bonus programs is still to be published, and a close assess-
ment of this data is required in view of the ethical issues raised by bonus
programs, including those flagged in this paper. It also appears that other
mechanisms beyond that of self-selection could be adopted. It would not be
conceptually impossible, for example, to offer bonuses only for the least
well-off. This might help make progress toward the aim of improving popu-
lation health and reducing health inequalities, even if bonuses might then
become less interesting as a marketing tool for attracting and retaining the
cheapest insurees (in the short or medium term). In any case, it seems clear
that the burden of proof that bonus systems are a useful way of promoting
health responsibility is on the side of the advocates of these programs.
ACKNOWLEDGEMENTS
I am most grateful for discussions of particular points with Stefanie Ettelt, Nicole Knaack, Elias Mossialos,
Alex Voorhoeve, and Joy Wang. The usual caveats apply. The views expressed here are the author’s alone and
must not be attributed to LSE Health or the Nuffield Council.
218 Harald Schmidt
NOTES
1. See Roemer (1994; 1995), Arneson (1997), and Dworkin (2000).
2. See Callahan (1999).
3. See Engelhardt (1976).
4. See English (2005), Iltis and Rasmussen (2005), and Schmidt (2007b).
5. See Wikler (1978), Wikler (2004), Cappelen and Norheim (2005), Feiring (2008), Gauthier (2005),
and Kelley (2005).
6. See Houtepen and Meulen (2000b).
7. See Schmidt (2008).
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