Rewarding healthy food choices in SNAP: behavioral economic applications.

CONTEXT: American obesity rates continue to escalate, but an effective policy response remains elusive. Specific changes to the Supplemental Nutrition Assistance Program (SNAP) have been proposed as one way to improve nutrition and combat obesity among lower-income populations. While current SNAP proposals hold promise, some important challenges still remain. METHODS: We discuss the four most common recommendations for changes to SNAP and their benefits and limitations. We then propose three new delivery options for SNAP that take advantage of behavioral economic insights and encourage the selection of healthy foods. FINDINGS: Although the existing proposals could help SNAP recipients, they often do not address some important behavioral impediments to buying healthy foods. We believe that behavioral economics can be used to design alternative policies with several advantages, although we recognize and discuss some of their limitations. The first proposal rewards healthy purchases with more SNAP funds and provides an additional incentive to maintain healthier shopping patterns. The second proposal uses the opportunity to win prizes to reward healthy food choices, and the prizes further support healthier habits. The final proposal simplifies healthy food purchases by allowing individuals to commit their SNAP benefits to more nutritious selections in advance. CONCLUSIONS: Reforming the delivery structure of SNAP's benefits could help improve nutrition, weight, and overall health of lower-income individuals. We advocate for more and diverse SNAP proposals, which should be tested and, possibly, combined. Their implementation, however, would require political will, administrative capacity, and funding.

Cost-benefit analysis of second-generation antipsychotics and placebo in a randomized trial of the treatment of psychosis and aggression in Alzheimer disease.

CONTEXT: Second-generation antipsychotics (SGAs) are prescribed for psychosis, aggression, and agitation in Alzheimer disease (AD). OBJECTIVE: To conduct a cost-benefit analysis of SGAs and placebo (taken to represent a "watchful waiting" treatment strategy) for psychosis and aggression in outpatients with AD. DESIGN: Randomized placebo-controlled trial of alternative SGA initiation strategies. SETTING: Forty-two outpatient clinics. PARTICIPANTS: Outpatients with AD and psychosis, aggression, or agitation (N = 421). Intervention Participants were randomly assigned to treatment with olanzapine, quetiapine fumarate, risperidone, or placebo with the option of double-blind rerandomization to another antipsychotic or citalopram hydrobromide or open treatment over 9 months. MAIN OUTCOME MEASURES: Monthly interviews documented health service use and costs. The economic perspective addressed total health care and medication costs. Costs of study drugs were estimated from wholesale prices with adjustment for discounts and rebates. Quality-adjusted life-years (QALYs) were assessed with the Health Utilities Index Mark 3 and were supplemented with measures of functioning, activities of daily living, and quality of life. Primary analyses were conducted using all available data. Secondary analyses excluded observations after the first medication change (ie, phase 1 only). Cost-benefit analysis was conducted using the net health benefits approach in a sensitivity analysis in which QALYs were valued at $50,000 per year and $100,000 per year. RESULTS: Average total health costs, including medications, were significantly lower for placebo than for SGAs, by $50 to $100 per month. There were no differences between treatments in QALYs or other measures of function. Phase 1-only analyses were broadly similar. Net-benefit analysis showed greater net health benefits for placebo as compared with other treatments, with probabilities ranging from 50% to 90%. CONCLUSIONS: There were no differences in measures of effectiveness between initiation of active treatments or placebo (which represented watchful waiting) but the placebo group had significantly lower health care costs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00015548.