What a sobriety chip knows that your wellness program doesn’t

A bronze Alcoholics Anonymous (AA) medallion retails for about $10. People carry them in a pocket or a wallet for decades, rub the face smooth with a thumb, and sometimes hand them to a newcomer who needs one more than they do. There isn’t a single patient engagement tool in American healthcare that earns that kind of loyalty, and we have spent a great deal more than $10 trying.

The behavioral scientist Kristen Berman recently explained how Starbucks Rewards work, and two of her points stuck with me. On the positive side, she notes that loyalty programs don’t try to transform anyone. They give you “a target that’s in line with what you already do” and win on the small stretch they ask of you: one extra visit or a slightly pricier order. That said, on the negative side of the Starbucks program, we know that status works best when other people can see it. Airline status is public, since everyone at the gate watches you board early, while your Starbucks stars sit quietly inside an app. As Berman puts it, “We all want to be the person who gets to cut the line.”

Healthcare can’t let patients cut the line, and nobody wants a pharmacy announcing their tier to the waiting room (I’m not sure nobody wants this, but let’s go with that.) Still, we can learn a lot from a status system like the AA medallions that has worked on one of the most difficult behaviors in medicine for more than 80 years, and that nobody in healthcare designed.

Why haven’t wellness incentives really changed anyone’s health?

Wellness programs typically pay the wrong people for the wrong things, and we know this because the experiment has been run rigorously. The Illinois Workplace Wellness Study randomized nearly 5,000 university employees to a program offering financial incentives and paid time off for screenings, health risk assessments, and wellness activities. After more than two years, screening rates were up, and there was no significant effect on other health behaviors, on medical spending, or on productivity. The most revealing finding came from before the program even started. The employees who chose to participate already had lower medical spending and healthier habits than those who didn’t. The money went largely to people who were already doing fine.

A clustered randomized trial across 160 BJ’s Wholesale Club locations told the same story. Employees at the intervention sites completed an average of 1.3 of the program’s eight modules. After 18 months, more of them reported exercising regularly and actively managing their weight, but there was no difference in cholesterol, blood pressure, body mass index, healthcare spending, or absenteeism. Even a seven-year observational study at PepsiCo, the kind of design that tends to support these programs, found the lifestyle component returned 48 cents for every dollar spent.

We need to look at what these programs actually reward. They pay points for outcomes the participant only partly controls, through an institution, in private, against a target someone in HR picked, and they stop when the program year does.

What does a sobriety chip do that a points program doesn’t?

AA chips reverse almost every one of those design choices, starting with the schedule. In many AA groups, the first year brings a token at 24 hours, then monthly until the bronze medallion at one year. That’s 13 milestones in the first year, concentrated at the front, which is exactly when the risk of relapse is highest. Nobody walking in on day one is asked to commit to a sober year, only to the next 24 hours, which is Berman’s small stretch in its purest form, built decades before anyone called it behavioral design.

The AA chip rewards effort, counted in days, rather than a lab value. A person’s liver enzymes are partly biology; showing up is not. A medallion is handed over in a room full of people who know exactly what those days cost, and their recognition is the whole reason a $10 coin matters. It also never expires. Nobody loses a one-year medallion because the plan year rolled over.

The setting has evidence behind it as well. A 2020 Cochrane review of 27 studies and more than 10,000 participants found that AA and similar 12-step facilitation produced higher rates of continuous abstinence at 12 months than established treatments such as cognitive behavioral therapy, with high-certainty evidence, and probably reduced healthcare costs as well.

Underneath the mechanics, the chip converts a behavior into an identity. A discount says you bought something. A chip says, “I am someone who is one year sober.” That conversion from transaction to identity is what the wellness programs never attempted.

Why can’t a health system just give out its own chip?

The status that matters isn’t issued by an institution, and AA is the proof. AA doesn’t make the chips, and there is no official AA medallion. Groups started handing them out on their own, reportedly in Indianapolis in 1942, and they remain a grassroots custom rather than something approved from the top. Their value comes entirely from who hands one to you.

Another issue is that programs end. Mitesh Patel’s STEP UP trial randomized 602 adults considered overweight or obese to a game built on behavioral economics. Participants wore a tracker, established how much they already walked, and chose their own step goal increase from that baseline. Then, they earned points and levels for hitting the goal, with a social element of support, collaboration, or competition. All three versions raised daily steps over 24 weeks, and competition did best, at 920 more steps per day than controls. When the game stopped, activity fell in every arm during the 12-week follow-up, and only the competition group was still significantly ahead of the controls. That was a well-designed program working as intended, and much of the effect still faded when the program ended.

Patel has also seen the status side of this from the inside. When he joined me on the “Designing for Health” podcast in 2024, he described the crowdsourcing tournament that launched the Penn Medicine Nudge Unit. Anyone in the health system could submit an idea, and the finalists competed for prizes: an iPad for one, gift cards for others. “But what people really like,” he told me, “was the opportunity to … pitch their idea in front of leadership,” with the CEO and the rest of the executive team in the room. The gift cards were a nice gesture, but the part people valued was being seen by the leaders whose opinion mattered to them, which is the chip’s logic applied to employees rather than patients.

To be clear, the chip works partly because the stakes for someone with alcohol use disorder are existential, and the community is intense. Prediabetes isn’t sobriety. A patient with a borderline A1c may never feel the need for a room full of people celebrating 90 days of walking, and I doubt a hospital can manufacture that need. A running app like Strava, where strangers give kudos for effort rather than pace, sits somewhere in the middle of that gradient, with lower stakes but a real community and a real, if fragile, sense of identity. Most chronic diseases will land somewhere along that range, which may mean something less than a medallion and still a good deal more than a gift card.

How can health systems design patient engagement that lasts?

Two levers would get most of the way there:

• Reset every patient’s target to one step beyond what the patient already does and put the milestones up front. Most patient goals arrive as finish lines (lose 7% of your body weight, exercise 150 minutes a week) that feel out of reach to precisely the people who most need them. Berman’s loyalty programs and the chip schedule agree on the alternative: Start from current behavior, reward the next small step, and mark it quickly, the way the first chip arrives at 24 hours rather than at the end of the year.
• Put the status inside the groups you already run and let the group confer on it. Health systems already host the rooms: National Diabetes Prevention Program cohorts, cardiac rehab classes, group prenatal care, shared medical appointments. What’s usually missing from them is recognition. Mark effort rather than outcomes, let patients opt in to being recognized, have the cohort do the recognizing, and make the milestones permanent. Then measure persistence, meaning whether people are still going a year after the program ends, rather than how many signed up.

Health systems are already very good at handing out points, badges, and gift cards. Far fewer of us have put real effort into hosting the rooms where recognition from peers carries weight, and that’s where the $10 coin gets its value.

A bronze medallion works because of where it was handed over and who was watching. A decade from now, what will a patient from your diabetes prevention cohort still be carrying in their pocket?