Imagine a simple trick that could significantly boost medication adherence among high-risk populations — but here's where it gets controversial... A recent study reveals that offering daily cash rewards nearly doubled the likelihood of people with high blood pressure taking their medication consistently. Surprisingly, however, this increased adherence did not translate into better blood pressure control. And this is the part most people miss: the link between pill-taking habits and actual health outcomes is far more complex than just providing incentives.
Let's delve into the findings from the Behavioral Economics Trial to Enhance Regulation of Blood Pressure (BETTER-BP), which was showcased during a late-breaking science session at the 2025 American Heart Association Scientific Sessions in New Orleans. The full research paper was also published in the Journal of the American College of Cardiology (JACC).
"Our goal has always been to discover effective strategies to improve medication adherence among patients with heart disease," explains Dr. John A. Dodson, the main investigator of the study. He’s the Director of NYU Langone’s Geriatric Cardiology Program and faculty member at NYU Langone Health’s Department of Medicine. “High blood pressure is one of the most preventable risk factors, so improving compliance could have enormous benefits.”
The trial involved 400 adults recruited from three community clinics in New York City, primarily serving Medicaid patients and those without insurance—groups often battling uncontrolled hypertension and struggling to follow prescribed medications. Since high blood pressure substantially increases the risk for heart attacks and strokes—yet is manageable with consistent medication use—the study aimed to see if behavioral nudges could make a difference.
Participants were divided randomly into two groups: approximately two-thirds entered a program where they could win small cash prizes for taking their medications, while the remaining third served as a control group, receiving no financial incentives. Notably, at the start, all participants admitted to inconsistent medication use.
To accurately measure pill-taking behavior, the researchers used electronic pill bottles that recorded every time they were opened — removing the biases often associated with self-reporting. At baseline, the average systolic blood pressure was 139 mm Hg (with the American Heart Association’s target being below 120 mm Hg).
Those in the reward group could enter daily drawings for cash prizes ranging from $5 to $50, but only if they had opened their pill bottle the day before, serving as a proxy for medication adherence. Each day, participants received a text message informing them if they had won. If they missed a dose, a reminder was sent, emphasizing the potential to earn rewards. The control group, meanwhile, did not receive texts or rewards.
The study extended over 12 months, divided into 6 months with incentives and 6 months without, to analyze whether behavioral changes persisted once the rewards ended.
Key discoveries from the trial include:
- Financial incentives effectively doubled medication adherence. During the incentive period, about 71% of participants in the rewards group took their medication regularly (at least 80% of the days), compared to just 34% in the control group.
- Despite higher adherence, both groups experienced similar reductions in blood pressure: an average drop of 6.7 mm Hg in the rewards group versus 5.8 mm Hg in the controls after six months.
- After the cessation of financial incentives, adherence rates in the rewards group plummeted back to baseline levels, indicating the difficulty in maintaining behavior change without ongoing motivation.
"While we saw clear evidence that financial rewards improved medication-taking behavior during the study, it didn't lead to significantly better blood pressure outcomes," notes Dr. Dodson. He highlights the uncertainty around whether participants truly took their medication despite opening the bottles, or if other untracked factors—such as different medication types or lifestyle changes—played a role. Furthermore, the decline in adherence post-incentives underscores how challenging it is to foster lasting health behaviors purely through monetary motivation.
This research sparks a crucial question: Are financial incentives enough to generate sustainable health improvements, or do we need more comprehensive strategies that address underlying behavioral, social, and psychological factors? Could relying solely on financial rewards sometimes undermine intrinsic motivation? And, importantly, what are the long-term implications for healthcare systems considering such approaches?
Study limitations include the fact that electronic pill bottles only tracked when bottles were opened—not necessarily if the medication was actually ingested. Also, only one medication per participant was monitored, despite many patients taking multiple drugs. Finally, blood pressure was measured only during clinic visits at predefined intervals, rather than through continuous or more frequent home monitoring, which might provide a different perspective on true control.
Study Details:
- Sample: 400 adults with diagnosed hypertension, prescribed at least one medication, with systolic readings above 140 mm Hg within the past year.
- Group Breakdown: 265 in the rewards group, 135 in control.
- Demographics: Median age 57; 60.5% women; 61.5% Hispanic, 20.3% Black, 3.3% White, 2.8% Asian, 12.3% other.
- Health Factors: 54.5% had obesity (BMI ≥30), and 46.5% had type 2 diabetes.
- Insurance Status: Over 70% were on Medicaid or uninsured.
Supported by the National Heart, Lung, and Blood Institute and the NIH (R01HL148275), the BETTER-BP study contributes valuable insights but also highlights the challenges in translating improved medication habits into better health outcomes.
What do you think? Are financial rewards a promising shortcut, or do they risk undermining intrinsic motivation for long-term health? Share your thoughts below — it’s a debate worth having.
