Financial Incentives Double Blood Pressure Medication Adherence But Fail to Improve Outcomes

A study presented at the American Heart Association's Scientific Sessions 2025 revealed that financial incentives significantly improved medication adherence among adults with high blood pressure, though this behavioral change did not translate to better clinical outcomes. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) study included 400 adults receiving care at three community health clinics in New York City, primarily serving Medicaid recipients and uninsured individuals who typically face higher rates of uncontrolled blood pressure.

Participants were randomly assigned to either a rewards group or control group, with two-thirds eligible for daily cash drawings ranging from $5 to $50 if they opened their electronic pill bottles. The study found that 71% of participants in the rewards group consistently took their medication during the six-month intervention period, compared to only 34% in the control group. This represents a doubling of medication adherence through financial incentives, demonstrating the powerful effect of behavioral economics on health behaviors.

Despite the dramatic improvement in medication adherence, both groups experienced similar blood pressure reductions. The rewards group showed an average systolic blood pressure reduction of 6.7 mm Hg, while the control group reduced by 5.8 mm Hg - a difference that was not statistically significant. This finding challenges conventional assumptions that improved medication adherence automatically leads to better clinical outcomes in hypertension management.

The study's principal investigator, Dr. John Dodson from NYU Grossman School of Medicine, expressed surprise at the results. "Financial incentives clearly worked to change behavior during the study period because people in the rewards group took their medication much more consistently. However, we were surprised that the behavior change didn't translate to significantly better blood pressure control," Dodson noted. The research was simultaneously published in the peer-reviewed journal JACC, available at https://www.jacc.org.

Perhaps most concerning was what happened when the financial incentives ended. During the six-month follow-up period after rewards were discontinued, participants in the rewards group reverted to their previous patterns of inconsistent medication use. This suggests that financial incentives create temporary behavior modification rather than lasting habit formation, raising important questions about the sustainability of such interventions in chronic disease management.

The study population reflected the challenges of managing hypertension in underserved communities. More than 70% of participants were covered by Medicaid or had no health insurance, and the cohort included significant representation from Hispanic (61.5%) and Black (20.3%) communities. These populations often face multiple barriers to consistent healthcare, including financial constraints, making the findings particularly relevant for public health policymakers.

Several limitations may explain the unexpected results. Electronic pill bottles only monitored bottle openings, not actual medication consumption. Researchers tracked only one blood pressure medication per participant, though many patients take multiple antihypertensive drugs. The study also relied on office-based blood pressure measurements rather than more frequent home monitoring, which might have provided different insights. Additional information about blood pressure management is available through the American Heart Association at https://www.heart.org.

The implications extend beyond hypertension management to broader questions about behavioral interventions in healthcare. While financial incentives can effectively modify behavior in the short term, they may not address the underlying factors that drive long-term medication adherence. The findings suggest that sustainable behavior change requires more comprehensive approaches that consider psychological, social, and environmental factors influencing health decisions.

For healthcare providers and policymakers, the study highlights both the potential and limitations of financial incentives in chronic disease management. While such programs can significantly improve short-term adherence, they may represent a costly intervention without corresponding clinical benefits if not carefully designed. The research underscores the need for more sophisticated approaches that combine financial incentives with other support mechanisms to achieve lasting health behavior changes.