Cash Rewards Double Blood Pressure Medication Use But Don't Improve Outcomes, Study Finds

A study of 400 adults with high blood pressure found that participants were twice as likely to take their blood pressure medication when offered daily chances to win cash rewards, yet they achieved similar blood pressure reductions compared to people not offered financial incentives. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) study included patients receiving care at three community health clinics in New York City, primarily serving Medicaid recipients and uninsured individuals who often have higher rates of uncontrolled blood pressure.

Participants were randomly assigned to either a rewards group or control group, with researchers using electronic pill bottles to monitor medication bottle openings as a measure of daily medication use. The average systolic blood pressure among all participants was 139 mm Hg at study enrollment, above the normal level of less than 120 mm Hg according to the American Heart Association's 2025 High Blood Pressure Guideline. Not taking blood pressure medication as directed can increase the risk of heart attack and stroke, according to the association.

During the six-month rewards program, participants in the incentives group were entered into daily drawings for cash rewards ranging from $5-$50 if they had opened their pill bottle the previous day. They received daily text messages informing them of any winnings, while those who skipped doses received reminders about potential missed rewards. The control group received no text messages or cash incentives.

Financial incentives doubled consistent medication use, with 71% of rewards group participants opening their medication regularly compared to 34% in the control group. However, both groups experienced similar systolic blood pressure reductions at six months - 6.7 mm Hg in the rewards group versus 5.8 mm Hg in the control group. After the cash rewards ended, participants in the incentives group reverted to their previous behavior of not consistently taking their medication as prescribed.

Principal investigator John Dodson, M.D., associate professor at NYU Grossman School of Medicine, expressed surprise that the behavior change didn't translate to significantly better blood pressure control. The findings were presented at the American Heart Association's Scientific Sessions 2025 and simultaneously published in the peer-reviewed journal JACC. The study highlights that improving medication adherence is more complex than initially thought, with many unknown factors affecting long-term behavior changes.

The research had several limitations, including that electronic pill bottles only monitored bottle openings rather than actual medication consumption. Researchers tracked only one blood pressure medication per participant despite many being prescribed multiple medications, and used standardized office measurements rather than more frequent home monitoring that might have yielded different results. The study population consisted mainly of Medicaid recipients or uninsured individuals, with 61.5% self-identifying as Hispanic and 20.3% as Black, reflecting the diverse patient populations often facing challenges with medication adherence.