You gotta play to win

Aetna is sponsoring a clinical trial of a daily low-stakes lottery to see whether it helps promote adherence among coumadin patients. According to the Hartford Courant (Lottery for Pill-Takers Could Be Healthy Bet), the unusual trial design features a daily one-in-five chance to win $10 and a one-in-100 chance to win $100. The expected value is $3 per day (1/5*$10+1/100*$100=$3), which amounts to $540 over the six-month trial. (It's not clear from the article if the odds for lottery participants improve when fewer people take their meds.)It's an unsual twist on the value based insurance design model and a variant on the negative co-pay concept I've advocated (When a $0 copay is too high).In order to be entered in the lottery a patient has to report taking their medication. Each patient will be issued a Med-eMonitor device and the patient will need to press the yes button on the device every day to confirm that they are taking their medicine.There are 50 patients in the lottery group and 50 patients in the control group, who will receive nothing. It wouldn't have occurred to me that a lottery was the best way to test out the concept, but it makes more sense now that I think of it. In particular, there is an addictive quality to lotteries that may motivate the drug takers to adhere.The experiment is interesting as far as it goes, but there are some other approaches that perhaps should be considered as well, such as:

• Rather than giving people a shot at winning, hand everybody the $540 up front, then make them pay out $3 every day they don't take their med. Those with perfect compliance at the end of the trial can then split the penalty pot.
• Introduce a support group aspect to the trial in order to get patients to encourage one another to take their meds. This could be done by increasing the size of the pot based on the group's overall level of compliance.
• Introduce incentives for coaches/mentors. For example, pay a reward to a coach who succeeds in having his/her coumadin adhere