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Walk Long and Prosper: What Is the Optimal Way to Help People Achieve Their Goals? Jeffrey S. Hoch, PhD 1,2 and Carolyn S. Dewa, MPH, PhD 3,4 Department of Public Health Sciences, University of California, Davis, CA, USA; 2 Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA; 3 Department of Psychiatry, University of California, Davis, Sacramento, CA, USA; 4 Behavioral Health Center of Excellence, University of California, Davis, Sacramento, CA, USA. J Gen Intern Med 31(7):712–3 DOI: 10.1007/s11606-016-3709-z © Society of General Internal Medicine 2016 n this month’s issue of the JGIM, Patel and colleagues 1 report the results of a randomized controlled trial (RCT) with the goal of increasing the activity of sedentary US em- ployees assigned to one of four reimbursement schemes. Over the 13-week intervention period, four-person teams were eli- gible for prizes based on achieving 7000 steps. Qualification for a prize was dependent on the reimbursement plan into which they were assigned. These included 1) $0 (control group), 2) $50 if the 7000 step goal was reached by the individual (individual incentive), 3) $50 if the 7000 step goal was reached by all team members (team incentive) or 4) $20 for reaching an individual goal of 7000 steps + $10 for every other team member reaching the goal (combined incentive). Receipt of a prize was contingent on winning a lottery that was held every other day during which a team from each of the four reimbursement plans was selected and paid according to its performance on the prior day. The article reports two major findings: 1) the combined incentive plan (i.e., reimbursement based on the combined performance of both the individual and the team members) was the most effective and 2) through time, the 7,000-step achievement waned regardless of the reimbursement scheme. The authors interpret these results as suggesting that the use of both individual and team incentives (i.e., a combined incentive plan) can boost performance. We would like to offer our observations about these results. First, incentives must sufficiently cover the costs of the activity that they seek to encourage. 2 For exam- ple, the individual incentive group (i.e., the group with the most potential to gain financially) was not relatively more likely to achieve the 7,000 step goal. One expla- nation could be that the monetary incentive was weak compared to the time cost (non-monetary disincentive) it would have taken to reach the goal. This begs the question, BHow large a monetary incentive is necessary to change the specific behavior that it seeks to modify?^ I Published online April 25, 2016 Second, reimbursement structures can have unintended consequences. For example, the authors observed that the combined incentive group totaled an average of just over 21,000 steps. 1 This 21,000 total step average is also consistent with a team using a designated non-walker arrangement. This could have happened if the combined incentive reimburse- ment scheme encouraged scheduled shirking. That is, team members could have agreed to work together to reach the common goal of getting the greatest pay-off with the least effort. This could have been done if all four members agreed to rotate who takes a day off from walking. This means only three members walked but the day’s designated non-walker did not. In addition, those who walked needed to take at least 7000 steps to achieve a team total of 21,000 steps and $120 in reimbursement. Without knowledge of this arrangement, it would appear that only the designated walkers received pay- ment. But, in reality, the team could allocate the total reward to everyone including the designated non-walker. Thus, both walkers and non-walkers could have been rewarded. In contrast, the team incentive model was supposed to enhance individuals’ accountability to teammates. Ultimately, this would lead to a common goal among all team members. If teamwork were the overriding motivation for participants in this study, we would have expected to see the team incentive producing the most steps. But, this was not the case. In fact, the team incentive arm of the study averaged only one step more than the control arm averaged during the 13 weeks (3930 vs. 3929 steps). For team incentive reimbursement plans, walking is only rewarded if everyone achieves 7000 steps. All it takes is for one person to fail for the team financial incentive to become equivalent to that of the control arm. This is the case because the under-achievers are not identifiable. If one’s team is given a $0 reward for its performance, it is common knowledge to those who walked that at least one person did not walk 7000 steps. But, it is not clear who failed. As a result, the impact of the accountability incentive is diluted. This suggests that with- out some accountability, the team incentive is not particularly effective. At the same time it should be noted that although there was no difference between the team incentive and control arms, the control groups did receive an intervention. This lack of differ- ence could be a consequence of the fact that the Bintervention^