Could cash be the key to losing weight?

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Though a largely forgettable writer of largely forgettable diet and self-help books, John Bjorn Bear, Ph.D., can lay claim to at least one weight-management epiphany that will stand up to history's retrospection: People will do just about anything for cash.

Also true is the converse -- penalize someone, financially and significantly, and he probably is more likely to lose 20 pounds than if you'd left him to his own methods.

Dr. Bear wrote the farcical "Blackmail Diet" more than two decades ago -- if you want to shed those stubborn pounds, sign a legally binding contract mandating a certain weight loss. And if you don't satisfy the contract's requirements, you must fork over, say, $5,000 to the American Nazi Party, which happens to be the precise deal Dr. Bear struck with himself.

Wouldn't ya know it? Those 70 pounds melted right off. (Although one poor reader, having failed to lose the weight, reported that he'd be donating his car to the Ku Klux Klan.)

"We have known this since the earliest times," he said when contacted in his California home. "The bigger the incentive, either positive or negative, the more likely it is to work." Behavioral scientists know it. Prophets in the Bible knew it -- screw up, and you'll go to hell. The penalties don't get much bigger than that.

Dr. Bear's creepy vision has arrived, and not just in the form of "The Biggest Loser," NBC's grotesque of a hit, featuring obese men and women trying to get in shape for a cash prize. Clinical studies and economists are more or less on his side. In recent months, health insurers, city mayors, British politicians and university professors have all come up with their own versions of plans that dangle dollar bills in front of clients and customers, hoping the carrot -- or a stiff penalty -- will be enough incentive to shape up.

United Healthcare, a national insurer trying to build a client base in Pennsylvania, is test-driving a high-deductible policy that will reduce the policyholder's deductible if he or she is healthy, or can make progress toward personal health goals over the year.

It's theoretically attractive to employers because it reduces their insurance costs. And United Healthcare hopes it's attractive to consumers who need an incentive, or a kick in the pocketbook, to get healthy.

"What we try to provide is a financial incentive for people to be healthy, or to strive to be healthy," said Dan Tropeano, United's vice president of sales.

The product, called "Vital Measures," has no customers yet in Pennsylvania, but would require employees to submit to a health screening to be eligible for the premium reduction. Employees who have good blood pressure, cholesterol and body-mass measures would be rewarded with thousands off their annual $2,500 deductible.

Such products can be controversial, at least in the health insurance realm -- the whole point of employer-based insurance, as opposed to individually procured insurance, is to get a bunch of people paying into one pot, spreading the cost and risk. But when you start charging different rates to different policyholders based on their theoretical health risks, the ones paying more don't like it.

Take smokers -- more employers are charging higher premiums to employees who smoke. But lawyers think this kind of private-life meddling is an invitation for a lawsuit, and might even be a violation of a federal law that says all workers covered under the same plan must pay the same premium, regardless of their health.

Yet the American obesity epidemic is so costly, in a health-care sense, that insurers and others are coming to think that incentives -- or is it blackmail? -- might be worth the risk of flouting federal law: The annual cost of providing medical care for an obese person is $1,244 more than the cost of someone with a "normal" body weight, one study says.

So if you can save thousands per person in health-care costs, and create a healthier work force too, what's a little binding contract between friends?

That's why two Yale professors, taking the baton from Dr. Bear, are launching a company called "StickK" -- dieters will sign a contract, over the Internet, requiring them to fork over a certain sum if they don't meet their weight-loss goals, much of which will go to a charity of someone else's choosing. Yale law professor Ian Ayres tested the method himself, staking $500 for each week he didn't lose at least a pound. And it worked.

"It's the risk of loss," he said, explaining why the prospect of losing $1,000 all at once is more motivating that the slow bleed of wasting $1,000 a year on an unused gym membership.

"That's a sunk cost," he said. You've already spent it, whether you do the push-ups or not.

"Cognitive economists have been fine-tuning what we know about the wellsprings of human behavior." And what they've found is that "loss aversion is a tremendous motivator."

But as United HealthCare hopes (and 'The Biggest Loser' has more or less shown), positive reinforcement may be just as effective as loss risk. Want clinical proof? A study by Dr. Eric Finkelstein showed that, when overweight dieters were divided into groups, the subjects being paid double the other group lost more than double the weight.

Whether that weight stays off is another matter, but Dr. Finkelstein said, for employers concerned about employee health and mulling the use of cash as a carrot, it's a fairly risk-free proposition. If you pay people to lose weight, and they don't lose weight, it doesn't cost you money, he said. On the other hand, popping for an employee gym can cost tens of thousands of dollars.

He was skeptical, however, of the bottom-line benefit to the company -- the people likely to lose pounds are those who are slightly overweight. But the biggest drain on a company's health-care outlays, the severely overweight or the obese, are less likely to take the challenge.

Then again, there's that law of economics -- "everybody has a price," the doctor said. "Anything you can do to make the cost of failure higher, is more likely to work."

Politicians are catching on -- mayors in cities across America and the world are challenging townsfolk to lose weight for cash. But the most interesting case study might be the United Kingdom, where last month, Parliament approved what by all accounts is a radical program to get Britons to lose some weight.

The government plans to spend roughly $740 million over three years on a plan encouraging employers to set up cash and prize incentive programs for employees who can lose weight, and reducing the proportion of overweight kids.

But doctors there were skeptical, according to U.K. media reports -- one said the plan smacked of "desperation."


Bill Toland can be reached at btoland@post-gazette.com or 412-263-2625.


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