FINANCIAL INCENTIVES FOR MEDICATION ADHERENCE
Why they have the potential to work
Do financial incentives work to improve medication adherence? While there are a limited number of studies that have examined the effects of financial incentives relative to the vast body of literature of other studies that have tried to improve medication adherence, interventions with financial incentives do show some promising results. For example, a recent large clinical trial was able to demonstrate that paid incentives can effectively promote adherence for statin medications in patients at risk for cardiovascular disease. One reason for this, as the researchers wrote is: “Financial incentives promote adherence by offering a salient reward for the typically distant effects of statins on cardiovascular disease”[1]. Offering patients such short-term rewards for healthy behavior can counteract something called present bias, or the tendency to overweight the immediate consequences of actions and underweight their future consequences[2] [3]. Present bias is a significant contributor to many harmful behaviors including non-adherence[4]. For example, patients with hypertension experience the inconvenience and financial costs of taking medications in the present, but, similar to taking statins for patients at risk for cardiovascular disease, the potential benefits lie far into the future and are not guaranteed for everyone[5]. Offering rewards in the present can compensate for a lack of intrinsic motivation and encourage long-term healthy habit formation.
Studies that have shown promising results
Unfortunately, most interventions that have tried to improve medication adherence have examined methods that are often complex, focusing primarily on counseling and educational support. These interventions have only had minimal success[6]. One reason is that they generally assume patients are rational and possess the self-control necessary for sticking with a long-term therapy plan. Interventions informed by behavioral economics, on the other hand, take into account the cognitive, psychological, emotional, and social processes that influence each patient’s decision-making. One key tool of such behavioral economics interventions is the use of financial incentives, which have shown intriguing results in broad areas of health including smoking cessation[7], physical activity[8], and eating habits[9]. With regards to adherence, a review of randomized trials in the United States found that 10 out of the 11 studies that offered patients cash, gifts or vouchers for adherence could demonstrate significant improvements relative to alternative treatments[10]. A further review of 15 studies concluded that financial incentives, among other approaches based on behavioral economics, could address the present bias preferences that prevent patients from improving their health[11]. Finally, a noteworthy study in Singapore had patients pay for their medications upfront and then refunded this payment only if adherence was satisfactory. This strategy leveraged another bias, loss aversion, or the fact that the pain felt from a loss is about twice as strong as the joy felt from a gain and people are therefore more compelled to avoid losses[12]. Thus, the intervention increased the motivational power of the financial incentives and was able to improve adherence by 12 percentage points relative to controls[13].
Our take: financial incentives based on loss aversion or combined with other behavioral economics approaches are more effective
We took a closer look at the effectiveness of studies using financial incentives in improving medication adherence (see the full scoping review[14] for the list of studies). In the chart below we plot whether these studies demonstrated significant effects (shown below the dashed line) relative to how many participants were included. Also shown are the size of the demonstrated effects (indicated by the color of the symbol). Like the scoping review, our examination emphasizes the complexity of the adherence issue, and we found that studies that used a combination of behavioral economic interventions that included financial incentives plus reinforcement or reminders were effective. We additionally highlight the effectiveness of studies using financial incentives based on loss aversion as well as studies using lottery-based financial incentives. Most of these studies found significant results with small to large effects (as assessed with Cohen’s d) [15]. Studies using financial incentives without loss aversion or other methods such as reinforcement or social influences by themselves were not as effective (not shown in chart).
More research is needed
Other combined approaches such as pairing commitment contracts with incentives[16] as well as frequently interacting with patients with incentives and reminders rather than giving one lump sum reward[17] may hold promise in promoting engagement and motivation. Overall, there is a clear necessity to tailor these multi-faceted interventions to the individual patient needs[14]. Furthermore, although there is evidence that financial incentives relying on loss aversion as well a combination of behavioral economics interventions including financial incentives have the potential to improve medication adherence, more studies are needed to investigate this in more detail, particularly with patients living in Central Europe. We are currently testing the effects of financial incentives on medication adherence through ongoing research.
Here we plot interventions with financial incentives by whether they demonstrated significant results on the y-axis compared to the total number of participants on the x-axis. Studies with significant results are shown below dashed line. Effect sizes are also indicated based on the color of the symbol representing the study. Most studies that used financial incentives based on loss aversion or lotteries as well as in combination with other behavioral economics approaches found significant results with small to large effects (assessed with Cohen’s d).
Find out more how Collabree supports better medication adherence:
If you would like to know more about our approach in detail or our ongoing research, feel free to get in touch here:
Dr. Anjali Raja Beharelle
CSO – Collabree AG
[email protected]
Pascal Kurz
CEO – Collabree AG
[email protected]
Literature
[1]: Barankay I, Reese PP, Putt ME, et al. Effect of Patient Financial Incentives on Statin Adherence and Lipid Control: A Randomized Clinical Trial. JAMA Netw Open. **3(**10):e2019429 (2020). [2]: O’Donoghue, T. & Rabin, M. Doing It Now or Later. Am. Econ. Rev. 89, 103–124 (1999). [3]: Thaler, R. Some empirical evidence on dynamic inconsistency. Econ. Lett. 8, 201–207 (1981). [4]: Wang, Y. & Sloan, F. A. Present bias and health. J. Risk Uncertain. 57, 177–198 (2018). [5]: Loewenstein, G., Brennan, T. & Volpp, K. G. Asymmetric Paternalism to Improve Health Behaviors. JAMA 298, 2415–2417 (2007). [6]: Schroeder, K., Fahey, T. & Ebrahim, S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst. Rev. (2004) doi:10.1002/14651858.cd004804 [7]: Halpern, S. D. et al. Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation. N. Engl. J. Med. 372, 2108–2117 (2015). [8]: Mitchell, M. S. et al. Financial Incentives for Exercise Adherence in Adults: Systematic Review and Meta-Analysis. Am. J. Prev. Med. 45, 658–667 (2013). [9]: Loewenstein, G., Price, J. & Volpp, K. Habit formation in children: Evidence from incentives for healthy eating. J. Health Econ. 45, 47–54 (2016). [10]: Giuffrida, A. & Torgerson, D. J. Should we pay the patient? Review of financial incentives to enhance patient compliance. Bmj 315, 703–707 (1997). [11]: Kullgren JT, Hafez D, Fedewa A, Heisler M. A scoping review of behavioral economic interventions for prevention and treatment of type 2 diabetes mellitus. Curr Diabetes Rep. 2017;17(9):73. [12]: Tversky, A. & Kahneman, D. Advances in prospect theory: Cumulative representation of uncertainty. J. Risk Uncertain. (1992) doi:10.1007/BF00122574. [13]: Bilger, M. et al. Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial. Appl. Health Econ. Health Policy 17, 841–855 (2019). [14]: Roseleur, J., Harvey, G., Stocks, N. & Karnon, J. Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review. Patient (2019) doi:10.1007/s40271-019-00377-8. [15]: https://en.wikipedia.org/wiki/Effect_size#Cohen’s_d [16]: van der Swaluw, K. et al. Commitment Lotteries Promote Physical Activity Among Overweight Adults—A Cluster Randomized Trial. Ann. Behav. Med. 52, 342–351 (2018). [17]: Volpp, K. G., Asch, D. A., Galvin, R. & Loewenstein, G. Redesigning employee health incentives - Lessons from behavioral economics. New England Journal of Medicine (2011) doi:10.1056/NEJMp1105966.
