Do financial incentives work to improve treatment adherence?

Pedro Rey
 

Laura Diego del Río & Pedro Rey

The effectiveness of a treatment depends as much on the prescriber's correct diagnosis and recommendations, as on whether the patient complies with the treatment guidelines that have been indicated. Lack of treatment adherence is one of the major problems related to medications, as it has a direct effect on both the effectiveness of the treatment and the healthcare costs. It’s estimated that in the group of patients with chronic diseases, adherence does not exceed 50%, with non-compliance being even higher in certain diseases, such as psychiatric diseases, in which it’s considered that only 25% of patients follow the treatment prescribed.

Lack of adherence to pharmacological treatments can be caused by multiple factors: lack of memory, cognitive difficulties to follow complex treatments in poly-medicated patients, rebellion against the feeling of dependence on drugs, little immediate visibility of the effects of the treatment... Therefore, a wide variety of strategies have been studied to improve adherence, targeting the different reasons that cause it. Although it’s not clear which is the optimal one in each case, there is agreement that the multidisciplinary and multiple agent approaches, with all the actors involved (health professionals, caregivers, family and the patients themselves) working in a structured and coordinated way, works best. Patient self-management programs, allowing to check and evaluate patients’ progression, have generally been shown to be effective in improving drug use, adherence and clinical outcomes, as well as reducing adverse effects. However, these strategies are not suitable for some specific populations such as patients with many morbidities, children or young people. Other actions, such as the simplification of therapeutic regimens or the review of medication, have shown benefits in adherence to treatment but need to be studied in greater depth. Finally, strategies such as reminders and educational interventions have yielded unclear results. 

Behavioral sciences study the design of interventions that favor the creation of healthy habits. As we have commented on this blog, in the healthcare environment there have been many experiments that have tried to implement behavioral changes among people who abuse substances, individuals seeking weight loss or pregnant smokers, as of those who want to increase their physical activity, for example. Many of these interventions have incorporated technological elements such as mobile applications or motivational aspects such as games. However, we also have an additional, purely Economic, tool, such as the use of financial incentives associated with achievements made by patients in the appropriate follow-up of their treatment.

An economic incentive, which does not necessarily have to be monetary (reimbursements, material goods or services), can encourage changes in certain behaviour among consumers, employees and even doctors and patients. The fundamental mechanism by which incentives work is by providing an individual extrinsic motivation to achieve a goal. In this way, they either add a reason that reinforces the behaviour or directly substitute the original motivation, so that the patient maintains treatment adherence not only out of concern for their health or for complying with the doctor's recommendations but because you are interested in getting the incentive. The reason why an incentive provides is of secondary importance in issues such as adherence to treatment, where the fundamental thing is the health of the patient and not so much the reasons why he behaves in one way or another. In other areas, there is some controversy about the use of incentives, such as in education, where there has been an intense ethical debate about whether incentives should be given to students to improve their grades or maintain their attendance at school. The reason is that in education, the student's motivation may be part of their conception of what education should be, while in health,  motivations are not in themselves as relevant, so long as the patient is remains healthy.

However, using financial incentives to improve treatment adherence comes with controversy. Cash payments have been used in patients of low socioeconomic status in developing countries such as Nigeria, Moldova, and Peru, where they have been shown to improve the health outcomes of tuberculosis treatment, even at the cost of some authors opposing the implicit paternalism that granting incentives entails. It’s relatively cheap for those who pay, but they represent an important part of the income of the recipients and, therefore, also of those who fail to meet the objective.

The ethical debate aside, the key question is whether the provision of incentives works both in the short and long term. Regarding the immediate effects of the incentives, those that occur while their provision is maintained, the results on adherence are reasonably positive. For example, cash payments for the use of long-acting injectable antipsychotics are effective without increasing healthcare costs. Other incentives, such as daily lotteries, have shown improvements in adherence to warfarin, even without showing improvements in controlling the international normalized ratio (INR). Finally, the cash payment of a basic salary ("family bag") to patients who completed treatment for tuberculosis increased the percentage of those who completed treatment from 68% to 78%, increasing rates by 8% healing.

Given that resources are scarce and expensive, and in many cases, the provision of incentives can only be done for a short period, it’s interesting to study whether the incentives create adherence habits so that, when withdrawn, the desired behaviour keeps up. In general, the available evidence shows that long-term results are much less promising, so the consensus is that so far it has not been possible to change adherence habits through incentives offered in a limited period, but rather these only work as long as they provide additional motivations or substitute for the original motivation of the patient.

In any case, and extending the discussion not only to adherence but also to the promotion of healthy habits in patients, there are many and varied situations in which simply achieving short-term behavioural changes can have important consequences for health. For example, while incentives have been shown to have little efficacy for long-term smoking cessation, they have proven to be very effective in populations of pregnant women (perhaps because multiple incentives were combined, not just monetary, but also social stigma suffered by a pregnant smoker), which has resulted in an improvement in the health of pregnant women and, especially, of their future babies.

Furthermore, the use of incentives should be considered for situations such as the current pandemic, in which individual behaviour (use of masks, personal hygiene, etc.) causes significant externalities in other people. The cost/benefit analysis of the provision of incentives in cases where the infectious explosion may have unimaginable economic consequences should therefore not be short-term.

Stopping a pandemic in time, even if it means having to pay incentives to a significant portion of the population for a relatively short period, could yield multiple long-term benefits.