Throwing Money at People to Force Them into Health
You may not know it, but some governments have begun to dole out money in an attempt to promote the health behaviors of certain citizen groups. Good idea? Bad idea?
First, some context by way of a 2019 Journal of the American Medical Association report (Thirumurthy, et al 2019) entitled "The Uncertain Effect of Financial Incentives to Improve Health Behaviors." Among other things, the article detailed several relevant studies. In one, 1503 cardiovascular patients were chosen from three American health care systems. For 12 months, the subjects were entered into a lottery in which they could win more than $1000, if they took their statin medication and lowered their LDL-C cholesterol. Three other studies focused on HIV positive patients in an attempt to increase their compliance with antiretroviral therapies so as to improve their abilities to suppress the virus. All three HIV studies provided their participants with financial incentives. In neither the cardiovascular study nor in any of the HIV studies did monetary rewards produced their desired outcomes.
After noting that some other studies had inferred health compliance benefit from financial inducements, Thirumurthy and his colleagues offered suggestions about how one might pay patients to take better care of their own health. Among other things, the authors cautioned against what they cited as the "Peanuts Effect" in which patients are paid too little to incentivize them. To quote, "These considerations suggest not being stingy with financial incentives when great value is at stake—or at least not assuming that incentives cannot be effective when small incentives do not succeed." After addressing several factors regarding patient monetary incentives, the authors subsequently reached the common sense conclusion that the manner in which a financial reward patient program is "designed" is central to its success.
What do you think? Should some big institution--almost always a government agency--pay people to behave in ways that profit those very same people? The United States tried paying children to attend school, and that mostly ended with fraud by the administrators and no significantly improved attendance by the students. Nevertheless, there still are pay-to-attend-school crusaders. Foremost among these is Brentin Mock (2017) who, writing for City Lab-- owned by The Atlantic, one of America's oldest literary magazines--asserted that "We need to pay high school students to go to school. I don’t mean some punk-ass weekly or monthly allowance, or a gift card for Dave & Busters. I’m talking about a deposit of somewhere in the ballpark of $50 to $100, every school day. That’s not for making honor roll; it’s just for making it to school in the morning and staying until the end of the day. Yes, compensated just for showing up. Think Universal Basic Income—but for kids." Critically evaluate that for a moment: If instituted, the recommendation would cost between $9,000 and $18,000 for each and every student. Based on 2013-2014 enrollment statistics, for Wyoming, the state with least students, the yearly cost would have ranged from 833 million, 67 thousand dollars at the low end to 1 billion, 666 million, 134 thousand dollars at the high end. For California, the state with most students, the yearly cost would have ranged from a low of 53 billion, 962 million, 686 thousand dollars at the low end to 107 billion, 925 million, 372 thousand dollars at the high end. Those new educational expenses, of course, would have to be added to Wyoming's usual pupil yearly expenditures of 1 billion, 560 million,764 thousand dollars, and added to California's usual pupil yearly expenditures of 72 billion, 641 million, 244 thousand dollars.
References
Dweck, C. (2006). Mindset: The New Psychology of Success. New York: Random House
Mock, B. (2017). We Will Pay High School Students To Go To School. And We Will Like It.
April 3. https://www.citylab.com/equity/2017/04/lets-just-pay-high-school-students-to-go-to-school/521694/
Ryan R. M., Deci E. L. (2017). Self-determination theory: Basic Psychological Needs in Motivation Development and Wellness. New York, NY: Guilford Press
Thirumurthy, H., Asch, D., & Volpp, K. (2019) The Uncertain Effect of Financial Incentives to Improve Health Behaviors. JAMA. 2019;321(15):1451-1452. doi:10.1001/jama.2019.2560
The Uncertain Effect of Financial Incentives to Improve Health Behaviors
If intrinsic motivations alone were enough to influence health behaviors, individuals would not smoke, all drivers would wear seat belts, and patients with chronic conditions would take their medications. Yet approximately half of patients prescribed single-drug therapy for hypertension discontinue their medications within a year,1even though presumably they want to avoid strokes and hopefully know that taking their medication is one way to reduce health risks. To supplement the intrinsic motivations apparently insufficient to the task, economists and others have long proposed extrinsic motivations in the form of financial rewards. These rewards offer the added benefit of being immediate rather than the typically delayed intrinsic rewards of better health sometime in the future. Studies in varied health domains have revealed that financial incentives work well. For example, a 2015 systematic review determined that to reduce smoking during pregnancy, financial or material incentives were more effective than other medical or behavioral strategies.2 The use of incentives is also widespread. In 2018, 86% of US employers offered some financial incentives for healthy behavior,3 and in lower-income countries, conditional cash transfer programs rewarded utilization of preventive services.
Nevertheless, providing financial incentives to patients does not always work. Recent studies raise important questions about why incentives sometimes fail to achieve behavior change.
Recent Disappointing Evidence on Incentives
In a randomized trial conducted in 3 US health care systems among 1503 patients with high cardiovascular disease risk, 12 months of daily lottery-based incentives to patients tied to their statin use and success at reducing low-density lipoprotein cholesterol (LDL-C) levels did not yield significant reduction in those levels.4 Another 12-month trial of social support and financial incentives to promote adherence to cardiovascular medications among 1509 patients following acute myocardial infarction found no reduction in clinical events or hospitalization, as well as no improvement in medication adherence.5 In both trials, patients who were adherent could earn more than $1000.
Three studies among people living with human immunodeficiency virus (HIV) infection have sought to increase viral suppression rates, which requires sustained adherence to antiretroviral therapy. In a US study involving 801 patients, patient navigation along with 6 months of incentives totaling more than $1000 conditional on adherence-related behaviors and viral suppression did not affect outcomes at 12 months.6 A trial of quarterly incentives of $70 linked to viral suppression involving 16 208 patients at 37 HIV care sites showed that viral suppression rates were only 3.8% higher at incentives sites compared with standard-care sites.7 A third trial in Uganda that included 400 patients showed that periodic incentives for viral suppression totaling $25 over 6 months did not affect viral suppression rates.8
These discouraging results could seem like evidence that patient financial incentives do not generally work, were it not for many other studies demonstrating that incentives do work9 and empirical support that people respond to incentives in everyday life. An important lesson is that seemingly small choices in how incentives are situated, framed, or deployed can have substantial effects on their success. Incentive interventions are typically a collection of subtle design choices; ie, each choice is potentially capable of changing the outcome if its individual influence could be isolated. Unlike evaluations of a new drug against an active or placebo control, pragmatic studies of incentive interventions inevitably test multiple possible active components together and sometimes against active controls. Learning from the failures of these trials requires examining their elemental parts.
Elemental Lessons
Enrollment of Self-Selected Patients
In many studies, participants were enrolled through an opt-in process engaging only a fraction of those eligible. Although the trials maintained high internal validity, external validity is much lower when only 10% to 15% of eligible patients enroll and those who participate are likely more motivated than those who do not. Participants who enter such trials are likely motivated to succeed with or without incentive, generally biasing results toward the null. Even if not, the most motivated patients rarely represent the population most in need of support, yet they are most often targeted by trials. These considerations recommend opt-out or unconsented trials in which trial enrollment is not inadvertently codetermined by factors incentives are designed to modify.
Active Control Conditions
In 3 trials noted above,4,5,8 control groups received wireless pill bottles, frequent outcome measurement, or generous participation incentives. The study that incentivized statin use provided up to $355 in participation incentives for quarterly cholesterol checks. These payments reduced differential attrition between study groups but also created an expectation and incentive among control group participants around ongoing cholesterol monitoring, likely increasing “success” rates. These considerations suggest careful attention to usual-care controls in substantially more pragmatic designs.
Timing of Enrollment
People cycle through “hot” and “cold” states in which their motivation varies, potentially determining their response to incentives. The study of acute myocardial infarction survivors recruited participants only after a processed insurance claim for acute myocardial infarction was released, which occurred an average of 40 days following hospital discharge. What seemed like an ineffective intervention might have been effective had patients been reached earlier. In subgroup analyses, the intervention was most effective among those who had already experienced a hospital readmission during those 40 days. Providing incentives at the time when risks of negative outcomes are higher will be more likely to generate desired changes in behavior.
Imperfect Execution
Patients do not have to understand the mechanism of action of drugs for those drugs to be effective. But a poorly understood financial incentive is unlikely to be effective. In a study of 23 023 employees with body mass index of 21 or higher at 2 US companies, those offered a 50% subsidy for a weight management program that increased to 100% after attaining attendance targets were equally likely to enroll and participate in the program as those offered only a 50% subsidy, suggesting that participants did not realize the former could be worth considerably more.10 Better communication of incentive designs might make such interventions more effective.
Peanuts Effects
Offering incentives that are too small for the context (a “peanuts effect”) can demotivate rather than motivate. In some studies, incentive amounts might have been too small to motivate substantial behavior change. High-stakes goals like HIV viral suppression can plausibly justify high incentive amounts. If successful, these can be highly cost-effective or even cost saving. These considerations suggest not being stingy with financial incentives when great value is at stake—or at least not assuming that incentives cannot be effective when small incentives do not succeed.
Design of Incentive-Based Interventions
The provision of immediate rewards is important for successful incentive interventions. In some trials, quarterly incentives may have been too infrequent for daily behaviors like medication adherence. Incentives framed as losses rather than gains, incentives based on combinations of individual and team goals, and incentives delivered simultaneously to patients and clinicians have shown promise and should receive greater consideration.
A Potential Way Forward
The principle that individuals respond to incentives has considerable empirical support. However, the magnitude of effects differs substantially based on the nature of the behavior, the size of the incentive, the population involved, the design, and the social context. The risk in failing to consider the often defining influence of these seemingly subtle design choices is not just that promising effects might be missed, but that negative studies will unduly influence an entire field.
Back to top
Article Information
Corresponding Author: David A. Asch, MD, Center for Health Care Innovation, University of Pennsylvania, 3400 Civic Center Blvd, 14-171, Philadelphia, PA 19104 (asch@wharton.upenn.edu).
Published Online: March 25, 2019. doi:10.1001/jama.2019.2560
Conflict of Interest Disclosures: Drs Asch and Volpp reported that they are partners in and part owners of VAL Health, a consulting firm that provides advice about the use of behavioral economics in health and health care. Dr Volpp reported receipt of grants from the National Institute of Aging and research funding from Hawaii Medical Services Association (BCBS of Horizon), CVS, Weight Watchers, and Oscar Insurance. No other disclosures were reported.
References
1.
Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653):1114-1117. doi:10.1136/bmj.39553.670231.25PubMedGoogle ScholarCrossref
2.
Cahill K, Hartmann-Boyce J, Perera R. Incentives for smoking cessation. Cochrane Database Syst Rev. 2015;(5):CD004307.PubMedGoogle Scholar
3.
Employers continue to expand well-being programs and increase financial incentives for employers [press release]. Washington, DC: National Business Group on Health; May 3, 2018.
4.
Asch DA, Troxel AB, Stewart WF, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA. 2015;314(18):1926-1935. doi:10.1001/jama.2015.14850
ArticlePubMedGoogle ScholarCrossref
5.
Volpp KG, Troxel AB, Mehta SJ, et al. Effect of electronic reminders, financial incentives, and social support on outcomes after myocardial infarction: the HeartStrong randomized clinical trial. JAMA Intern Med. 2017;177(8):1093-1101. doi:10.1001/jamainternmed.2017.2449
ArticlePubMedGoogle ScholarCrossref
6.
Metsch LR, Feaster DJ, Gooden L, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. JAMA. 2016;316(2):156-170. doi:10.1001/jama.2016.8914
ArticlePubMedGoogle ScholarCrossref
7.
El-Sadr WM, Donnell D, Beauchamp G, et al; HPTN 065 Study Team. Financial incentives for linkage to care and viral suppression among HIV-positive patients: a randomized clinical trial (HPTN 065). JAMA Intern Med. 2017;177(8):1083-1092. doi:10.1001/jamainternmed.2017.2158
ArticlePubMedGoogle ScholarCrossref
8.
Thirumurthy H, Ndyabakira A, Marson K, et al. Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial. Lancet HIV. 2019;6(3):e155-e163. doi:10.1016/S2352-3018(18)30330-8PubMedGoogle ScholarCrossref
9.
Mantzari E, Vogt F, Shemilt I, Wei Y, Higgins JPT, Marteau TM. Personal financial incentives for changing habitual health-related behaviors: a systematic review and meta-analysis. Prev Med. 2015;75:75-85. doi:10.1016/j.ypmed.2015.03.001PubMedGoogle ScholarCrossref
10.
John LK, Troxel AB, Yancy WS Jr, et al. The effect of cost sharing on an employee weight loss program: a randomized trial. Am J Health Promot. 2018;32(1):170-176. doi:10.1177/0890117116671282PubMedGoogle ScholarCrossref
First, some context by way of a 2019 Journal of the American Medical Association report (Thirumurthy, et al 2019) entitled "The Uncertain Effect of Financial Incentives to Improve Health Behaviors." Among other things, the article detailed several relevant studies. In one, 1503 cardiovascular patients were chosen from three American health care systems. For 12 months, the subjects were entered into a lottery in which they could win more than $1000, if they took their statin medication and lowered their LDL-C cholesterol. Three other studies focused on HIV positive patients in an attempt to increase their compliance with antiretroviral therapies so as to improve their abilities to suppress the virus. All three HIV studies provided their participants with financial incentives. In neither the cardiovascular study nor in any of the HIV studies did monetary rewards produced their desired outcomes.
After noting that some other studies had inferred health compliance benefit from financial inducements, Thirumurthy and his colleagues offered suggestions about how one might pay patients to take better care of their own health. Among other things, the authors cautioned against what they cited as the "Peanuts Effect" in which patients are paid too little to incentivize them. To quote, "These considerations suggest not being stingy with financial incentives when great value is at stake—or at least not assuming that incentives cannot be effective when small incentives do not succeed." After addressing several factors regarding patient monetary incentives, the authors subsequently reached the common sense conclusion that the manner in which a financial reward patient program is "designed" is central to its success.
What do you think? Should some big institution--almost always a government agency--pay people to behave in ways that profit those very same people? The United States tried paying children to attend school, and that mostly ended with fraud by the administrators and no significantly improved attendance by the students. Nevertheless, there still are pay-to-attend-school crusaders. Foremost among these is Brentin Mock (2017) who, writing for City Lab-- owned by The Atlantic, one of America's oldest literary magazines--asserted that "We need to pay high school students to go to school. I don’t mean some punk-ass weekly or monthly allowance, or a gift card for Dave & Busters. I’m talking about a deposit of somewhere in the ballpark of $50 to $100, every school day. That’s not for making honor roll; it’s just for making it to school in the morning and staying until the end of the day. Yes, compensated just for showing up. Think Universal Basic Income—but for kids." Critically evaluate that for a moment: If instituted, the recommendation would cost between $9,000 and $18,000 for each and every student. Based on 2013-2014 enrollment statistics, for Wyoming, the state with least students, the yearly cost would have ranged from 833 million, 67 thousand dollars at the low end to 1 billion, 666 million, 134 thousand dollars at the high end. For California, the state with most students, the yearly cost would have ranged from a low of 53 billion, 962 million, 686 thousand dollars at the low end to 107 billion, 925 million, 372 thousand dollars at the high end. Those new educational expenses, of course, would have to be added to Wyoming's usual pupil yearly expenditures of 1 billion, 560 million,764 thousand dollars, and added to California's usual pupil yearly expenditures of 72 billion, 641 million, 244 thousand dollars.
Just for the moment, set aside the expense. Instead, be aware that research over the decades has proven that external rewards destroy intrinsic motivation (Ryan & Deci, 2017). So paying people to force them into physical and mental health easily could backfire. For instance, studies (Dweck, 2006) have found that when external rewards are withdrawn, those previously rewarded tend to return to their pre-existing behaviors. And what about those who already had the intrinsic motivation to behave healthfully before financial incentives were offered? Might they not rebel, demanding to be paid as much, or more, than the slackers in order to continue behaving healthfully?
References
Dweck, C. (2006). Mindset: The New Psychology of Success. New York: Random House
Mock, B. (2017). We Will Pay High School Students To Go To School. And We Will Like It.
April 3. https://www.citylab.com/equity/2017/04/lets-just-pay-high-school-students-to-go-to-school/521694/
Ryan R. M., Deci E. L. (2017). Self-determination theory: Basic Psychological Needs in Motivation Development and Wellness. New York, NY: Guilford Press
Thirumurthy, H., Asch, D., & Volpp, K. (2019) The Uncertain Effect of Financial Incentives to Improve Health Behaviors. JAMA. 2019;321(15):1451-1452. doi:10.1001/jama.2019.2560
The Uncertain Effect of Financial Incentives to Improve Health Behaviors
If intrinsic motivations alone were enough to influence health behaviors, individuals would not smoke, all drivers would wear seat belts, and patients with chronic conditions would take their medications. Yet approximately half of patients prescribed single-drug therapy for hypertension discontinue their medications within a year,1even though presumably they want to avoid strokes and hopefully know that taking their medication is one way to reduce health risks. To supplement the intrinsic motivations apparently insufficient to the task, economists and others have long proposed extrinsic motivations in the form of financial rewards. These rewards offer the added benefit of being immediate rather than the typically delayed intrinsic rewards of better health sometime in the future. Studies in varied health domains have revealed that financial incentives work well. For example, a 2015 systematic review determined that to reduce smoking during pregnancy, financial or material incentives were more effective than other medical or behavioral strategies.2 The use of incentives is also widespread. In 2018, 86% of US employers offered some financial incentives for healthy behavior,3 and in lower-income countries, conditional cash transfer programs rewarded utilization of preventive services.
Nevertheless, providing financial incentives to patients does not always work. Recent studies raise important questions about why incentives sometimes fail to achieve behavior change.
Recent Disappointing Evidence on Incentives
In a randomized trial conducted in 3 US health care systems among 1503 patients with high cardiovascular disease risk, 12 months of daily lottery-based incentives to patients tied to their statin use and success at reducing low-density lipoprotein cholesterol (LDL-C) levels did not yield significant reduction in those levels.4 Another 12-month trial of social support and financial incentives to promote adherence to cardiovascular medications among 1509 patients following acute myocardial infarction found no reduction in clinical events or hospitalization, as well as no improvement in medication adherence.5 In both trials, patients who were adherent could earn more than $1000.
Three studies among people living with human immunodeficiency virus (HIV) infection have sought to increase viral suppression rates, which requires sustained adherence to antiretroviral therapy. In a US study involving 801 patients, patient navigation along with 6 months of incentives totaling more than $1000 conditional on adherence-related behaviors and viral suppression did not affect outcomes at 12 months.6 A trial of quarterly incentives of $70 linked to viral suppression involving 16 208 patients at 37 HIV care sites showed that viral suppression rates were only 3.8% higher at incentives sites compared with standard-care sites.7 A third trial in Uganda that included 400 patients showed that periodic incentives for viral suppression totaling $25 over 6 months did not affect viral suppression rates.8
These discouraging results could seem like evidence that patient financial incentives do not generally work, were it not for many other studies demonstrating that incentives do work9 and empirical support that people respond to incentives in everyday life. An important lesson is that seemingly small choices in how incentives are situated, framed, or deployed can have substantial effects on their success. Incentive interventions are typically a collection of subtle design choices; ie, each choice is potentially capable of changing the outcome if its individual influence could be isolated. Unlike evaluations of a new drug against an active or placebo control, pragmatic studies of incentive interventions inevitably test multiple possible active components together and sometimes against active controls. Learning from the failures of these trials requires examining their elemental parts.
Elemental Lessons
Enrollment of Self-Selected Patients
In many studies, participants were enrolled through an opt-in process engaging only a fraction of those eligible. Although the trials maintained high internal validity, external validity is much lower when only 10% to 15% of eligible patients enroll and those who participate are likely more motivated than those who do not. Participants who enter such trials are likely motivated to succeed with or without incentive, generally biasing results toward the null. Even if not, the most motivated patients rarely represent the population most in need of support, yet they are most often targeted by trials. These considerations recommend opt-out or unconsented trials in which trial enrollment is not inadvertently codetermined by factors incentives are designed to modify.
Active Control Conditions
In 3 trials noted above,4,5,8 control groups received wireless pill bottles, frequent outcome measurement, or generous participation incentives. The study that incentivized statin use provided up to $355 in participation incentives for quarterly cholesterol checks. These payments reduced differential attrition between study groups but also created an expectation and incentive among control group participants around ongoing cholesterol monitoring, likely increasing “success” rates. These considerations suggest careful attention to usual-care controls in substantially more pragmatic designs.
Timing of Enrollment
People cycle through “hot” and “cold” states in which their motivation varies, potentially determining their response to incentives. The study of acute myocardial infarction survivors recruited participants only after a processed insurance claim for acute myocardial infarction was released, which occurred an average of 40 days following hospital discharge. What seemed like an ineffective intervention might have been effective had patients been reached earlier. In subgroup analyses, the intervention was most effective among those who had already experienced a hospital readmission during those 40 days. Providing incentives at the time when risks of negative outcomes are higher will be more likely to generate desired changes in behavior.
Imperfect Execution
Patients do not have to understand the mechanism of action of drugs for those drugs to be effective. But a poorly understood financial incentive is unlikely to be effective. In a study of 23 023 employees with body mass index of 21 or higher at 2 US companies, those offered a 50% subsidy for a weight management program that increased to 100% after attaining attendance targets were equally likely to enroll and participate in the program as those offered only a 50% subsidy, suggesting that participants did not realize the former could be worth considerably more.10 Better communication of incentive designs might make such interventions more effective.
Peanuts Effects
Offering incentives that are too small for the context (a “peanuts effect”) can demotivate rather than motivate. In some studies, incentive amounts might have been too small to motivate substantial behavior change. High-stakes goals like HIV viral suppression can plausibly justify high incentive amounts. If successful, these can be highly cost-effective or even cost saving. These considerations suggest not being stingy with financial incentives when great value is at stake—or at least not assuming that incentives cannot be effective when small incentives do not succeed.
Design of Incentive-Based Interventions
The provision of immediate rewards is important for successful incentive interventions. In some trials, quarterly incentives may have been too infrequent for daily behaviors like medication adherence. Incentives framed as losses rather than gains, incentives based on combinations of individual and team goals, and incentives delivered simultaneously to patients and clinicians have shown promise and should receive greater consideration.
A Potential Way Forward
The principle that individuals respond to incentives has considerable empirical support. However, the magnitude of effects differs substantially based on the nature of the behavior, the size of the incentive, the population involved, the design, and the social context. The risk in failing to consider the often defining influence of these seemingly subtle design choices is not just that promising effects might be missed, but that negative studies will unduly influence an entire field.
Back to top
Article Information
Corresponding Author: David A. Asch, MD, Center for Health Care Innovation, University of Pennsylvania, 3400 Civic Center Blvd, 14-171, Philadelphia, PA 19104 (asch@wharton.upenn.edu).
Published Online: March 25, 2019. doi:10.1001/jama.2019.2560
Conflict of Interest Disclosures: Drs Asch and Volpp reported that they are partners in and part owners of VAL Health, a consulting firm that provides advice about the use of behavioral economics in health and health care. Dr Volpp reported receipt of grants from the National Institute of Aging and research funding from Hawaii Medical Services Association (BCBS of Horizon), CVS, Weight Watchers, and Oscar Insurance. No other disclosures were reported.
References
1.
Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653):1114-1117. doi:10.1136/bmj.39553.670231.25PubMedGoogle ScholarCrossref
2.
Cahill K, Hartmann-Boyce J, Perera R. Incentives for smoking cessation. Cochrane Database Syst Rev. 2015;(5):CD004307.PubMedGoogle Scholar
3.
Employers continue to expand well-being programs and increase financial incentives for employers [press release]. Washington, DC: National Business Group on Health; May 3, 2018.
4.
Asch DA, Troxel AB, Stewart WF, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA. 2015;314(18):1926-1935. doi:10.1001/jama.2015.14850
ArticlePubMedGoogle ScholarCrossref
5.
Volpp KG, Troxel AB, Mehta SJ, et al. Effect of electronic reminders, financial incentives, and social support on outcomes after myocardial infarction: the HeartStrong randomized clinical trial. JAMA Intern Med. 2017;177(8):1093-1101. doi:10.1001/jamainternmed.2017.2449
ArticlePubMedGoogle ScholarCrossref
6.
Metsch LR, Feaster DJ, Gooden L, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. JAMA. 2016;316(2):156-170. doi:10.1001/jama.2016.8914
ArticlePubMedGoogle ScholarCrossref
7.
El-Sadr WM, Donnell D, Beauchamp G, et al; HPTN 065 Study Team. Financial incentives for linkage to care and viral suppression among HIV-positive patients: a randomized clinical trial (HPTN 065). JAMA Intern Med. 2017;177(8):1083-1092. doi:10.1001/jamainternmed.2017.2158
ArticlePubMedGoogle ScholarCrossref
8.
Thirumurthy H, Ndyabakira A, Marson K, et al. Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial. Lancet HIV. 2019;6(3):e155-e163. doi:10.1016/S2352-3018(18)30330-8PubMedGoogle ScholarCrossref
9.
Mantzari E, Vogt F, Shemilt I, Wei Y, Higgins JPT, Marteau TM. Personal financial incentives for changing habitual health-related behaviors: a systematic review and meta-analysis. Prev Med. 2015;75:75-85. doi:10.1016/j.ypmed.2015.03.001PubMedGoogle ScholarCrossref
10.
John LK, Troxel AB, Yancy WS Jr, et al. The effect of cost sharing on an employee weight loss program: a randomized trial. Am J Health Promot. 2018;32(1):170-176. doi:10.1177/0890117116671282PubMedGoogle ScholarCrossref
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