Financial Incentives Double Blood Pressure Medication Use But Don't Improve Outcomes, Study Finds

People with high blood pressure were twice as likely to take their prescribed medication when offered daily chances to win cash rewards, yet they achieved similar blood pressure reductions compared to patients not receiving financial incentives, according to research presented at the American Heart Association's Scientific Sessions 2025. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) study followed 400 adults with high blood pressure who received care at three New York City community health clinics serving primarily Medicaid recipients and uninsured individuals.

The study's findings challenge conventional assumptions about medication adherence and health outcomes. During the six-month rewards program, 71% of participants in the incentives group consistently opened their medication bottles compared to only 34% in the control group. However, both groups experienced nearly identical blood pressure improvements - a 6.7 mm Hg reduction in the rewards group versus 5.8 mm Hg in the control group. This unexpected outcome suggests that simply increasing medication adherence through financial incentives may not translate to better clinical results.

Dr. John Dodson, principal investigator of the study and associate professor at 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," he said. The research raises questions about whether participants actually consumed the medication after opening bottles or if other factors like additional medications or lifestyle behaviors influenced outcomes.

Perhaps most concerning was what happened when the financial incentives ended. The study monitored participants for an additional six months after the rewards program concluded and found that those who had received cash incentives reverted to their previous patterns of inconsistent medication use. This finding has significant implications for healthcare systems considering financial incentive programs, as it suggests temporary rewards may not create lasting behavior change.

The study population represented a high-risk group for cardiovascular complications. More than 70% of participants were covered by Medicaid or uninsured, populations that typically have higher rates of uncontrolled blood pressure. According to American Heart Association guidelines available at heart.org/en/health-topics/high-blood-pressure, not taking blood pressure medication as directed increases the risk of heart attack and stroke. The average systolic blood pressure among participants was 139 mm Hg at enrollment, above the normal threshold of less than 120 mm Hg defined in the 2025 High Blood Pressure Guideline.

Researchers used electronic pill bottles to monitor medication bottle openings rather than relying on patient self-reporting, providing more objective adherence data. Participants in the rewards group received daily text messages informing them of potential winnings ranging from $5 to $50 if they had opened their medication bottle the previous day. Those who skipped doses received reminders about missed reward opportunities.

The study's limitations include the inability to confirm whether participants actually consumed medication after opening bottles and the monitoring of only one blood pressure medication per participant, though many were prescribed multiple drugs. The research was simultaneously published in the peer-reviewed journal JACC, adding credibility to its findings. The results highlight the need for more comprehensive approaches to medication adherence that address underlying barriers beyond financial incentives alone.