Here’s a startling fact: despite high blood pressure being one of the most preventable risk factors for heart attacks and strokes, millions of people still struggle to manage it effectively. But what if a simple financial incentive could double the likelihood of patients taking their medication regularly? A groundbreaking study has explored this very question, and the results are both intriguing and surprisingly complex.
The Behavioral Economics Trial to Enhance Regulation of Blood Pressure (BETTER-BP) revealed that individuals with high blood pressure were twice as likely to adhere to their medication regimen when offered daily cash rewards. However—and this is the part most people miss—these participants did not achieve significantly better blood pressure control compared to those who received no financial incentives. So, what’s going on here?
Presented at the American Heart Association’s Scientific Sessions 2025 in New Orleans and published in the Journal of the American College of Cardiology (JACC), the study sheds light on the challenges of improving medication adherence in high-risk, low-income populations. Led by Dr. John A. Dodson, director of NYU Langone’s Geriatric Cardiology Program, the research involved 400 adults from three New York City community health clinics. These clinics primarily serve Medicaid recipients and uninsured patients—groups disproportionately affected by uncontrolled blood pressure and treatment non-adherence.
Participants were randomly divided into two groups: one with the chance to win daily cash prizes (ranging from $5 to $50) for taking their medication, and a control group without incentives. To ensure accuracy, researchers used electronic pill bottles that tracked when participants opened them, rather than relying on self-reports. At the start, the average systolic blood pressure was 139 mm Hg—well above the American Heart Association’s 2025 guideline of below 120 mm Hg.
Here’s where it gets controversial: while financial incentives clearly doubled consistent medication use (71% in the rewards group vs. 34% in the control group), both groups experienced similar drops in blood pressure after six months (6.7 mm Hg vs. 5.8 mm Hg). Even more surprising? Once the rewards stopped, adherence rates plummeted, returning to pre-study levels.
Why didn’t better adherence translate to better outcomes? Dr. Dodson speculates that participants might have opened the bottles without actually taking the medication, or that other factors—like lifestyle choices or multiple medications—played a role. This raises a thought-provoking question: Can external rewards truly drive long-term behavior change, or are they just a temporary Band-Aid?
The study’s limitations add another layer of complexity. Electronic pill bottles tracked bottle openings but not actual medication ingestion. Researchers also monitored only one blood pressure medication per participant, despite many taking multiple drugs. Additionally, blood pressure was measured in clinic just three times over 12 months, rather than through more frequent home monitoring.
Demographically, the study included participants with a median age of 57, 60.5% of whom were women. The majority identified as Hispanic (61.5%) or Black (20.3%), and over 70% were covered by Medicaid or uninsured. Many also had comorbidities like obesity (54.5%) and type 2 diabetes (46.5%).
Supported by the National Heart, Lung, and Blood Institute, BETTER-BP highlights the intricate nature of behavior change. While financial incentives can be a powerful short-term motivator, their long-term effectiveness remains uncertain. What do you think? Are rewards a viable solution for improving medication adherence, or do we need to address deeper systemic or behavioral issues? Share your thoughts in the comments—this is a conversation worth having.
