A study presented at the American Heart Association’s 2025 Scientific Sessions reveals that daily cash incentives doubled hypertension medication adherence but did not lead to improved blood pressure outcomes.
The BETTER-BP trial, conducted among 400 adults receiving care at community health clinics in New York City, found that while financial rewards significantly increased daily pill-taking behavior, this change did not translate into better blood pressure control compared to a non-incentivized control group.
Trial Design and Participant Profile
The study enrolled adults with hypertension who self-reported poor medication adherence prior to the trial. Participants were predominantly low-income individuals, with over 70% receiving Medicaid or being uninsured.
The median age was 57 years, 60.5% were female, and the majority identified as Hispanic (61.5%) or Black (20.3%). Additionally, 54.5% had obesity and 46.5% had type 2 diabetes. Participants were randomized to either a cash-incentivized group (n=265) or a control group (n=135).
Intervention and Monitoring Methodology
The incentivized group participated in a daily lottery where they could win 50 if their electronic pill bottle was opened the previous day, indicating medication intake.
They received daily text messages notifying them of wins or reminding them of potential rewards if they missed a dose. The control group received no financial incentives or messages. Electronic monitoring tracked pill bottle openings for 12 months: 6 months with incentives and 6 months without.
Primary Outcomes and Unexpected Results
The incentivized group showed 71% regular medication adherence (opening pill bottles ≥80% of days) compared to 34% in the control group during the 6-month intervention period. However, blood pressure reductions were similar between groups: a 6.7 mmHg drop in the incentive group versus 5.8 mmHg in controls. After incentives ended, adherence in the intervention group returned to pre-trial levels.
Interpretation and Implications
Senior investigator Dr. John Dodson noted: “Financial incentives clearly changed short-term behavior, but we were surprised that this didn’t lead to significantly better blood pressure control.”
The findings suggest that improving clinical outcomes requires more than just increasing pill-taking—it may also involve addressing other factors such as medication timing, lifestyle behaviors, or the complexity of multi-drug regimens. The rapid return to poor adherence after incentives ended highlights the challenge of sustaining behavior change without ongoing support.
Limitations and Future Research
The study had several limitations: electronic monitors recorded bottle openings but not actual medication ingestion; only one medication was monitored per patient despite many taking multiple drugs; and blood pressure was measured in-clinic rather than through home monitoring. Future research should explore whether combining financial incentives with other support strategies can produce both behavioral and clinical improvements that persist beyond the intervention period.
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