Financial Incentives for Adherence: Do They Pay?

TABLE. Behaviors that have been improved by financial incentive interventions

In everyday life, financial incentives encourage behaviors of consumers, employees, and even physicians (pay-for-performance). Financial incentives-including direct cash, refunds/rebates, or material goods and services-can also affect patients’ behaviors.

Contingency management

Financial interventions for substance use disorders, often called contingency management, involve provision of monetary-based reinforcers for submission of drug-negative urine specimens. These highly effective interventions are based on the principle that a behavior that is reinforced will increase in frequency. For example, in a nationwide study, 415 patients with stimulant use disorders were randomized to usual care alone or with incentives.¹ Patients randomized to incentives evidenced an average of nearly 2 more weeks of continuous abstinence, and 18.7% of incentive patients maintained abstinence throughout the entire 12 weeks versus 4.9% of the usual-care group.

For these interventions to be effective, urine samples (or other objective indices of abstinence) must be collected frequently (eg, 2 to 3 times per week) to detect and rapidly reinforce abstinence. Reinforcers are typically vouchers, exchangeable for retail goods, or chances to draw from a bowl and win prizes worth up to $100. The incentives need to be of sufficient magnitude and increase with sustained abstinence. In voucher systems, patients typically earn up to $1200 over a 12-week period; however, $300 in prize incentives can also be effective.

Incentive interventions are most widely applied for treating stimulant and opioid use disorders, because monitoring abstinence for these drugs is readily aligned with reinforcement principles. Reinforcing smoking or alcohol abstinence is also possible, but Breathalyzers and carbon monoxide devices can only detect use over very short periods. Detection of alcohol use in patients’ natural environments is now possible with devices that monitor alcohol in perspiration or remote Breathalyzers and is effective in reducing drinking and smoking when paired with incentive interventions.^2,3

Applicability to other patient populations

Financial incentive interventions are applicable to substance use populations, and they can also be used with patients who have other psychiatric problems. The Table outlines patient behaviors that have been addressed by these interventions.

Treatments for most mental disorders have high rates of attrition. When financially based incentives are provided for coming to substance abuse treatment sessions, attendance increases markedly.⁴ A low-cost, prize-based approach can be very effective. At an HIV drop-in center for group therapy, $20 per group increased attendance at least two-fold.⁵

Financial incentive interventions can also improve adherence to medications, which is problematic for many patients who have mental health disorders. Typically, this approach involves directly observed adherence, remote monitoring via electronic bottles, or video-recording medication consumption. In one study of dual diagnosis patients, an incentive of £15 for taking depot antipsychotics improved adherence to 85%.⁶

Many psychiatric patients are sedentary and overweight. Incentive interventions are useful in reinforcing adherence to weight loss regimens and exercise. Objective evidence of behavior change (in-person weigh-ins and direct or remote monitoring of physical activity) is necessary. Although the efficacy of these approaches has not been tested explicitly in psychiatric populations, sedentary non-patients randomized to an incentive intervention group met physical activity goals on more than 80% of days compared with 55% of days for the non-incentive group.⁷

Incentive interventions can also be used in diabetes management. For example, blood glucose testing increased from an average of 1.8 to 4.9 times per day among adolescents with poorly controlled type 1 diabetes who received reinforcers for testing-90% completed the recommended 4 or more tests daily.⁸ These procedures have not been tested directly in psychiatric patients with diabetes, but the guiding principles are generalizable.

Any behavior that can be objectively monitored can be reinforced. If the incentive system is properly designed, it is likely to be effective in altering the behavior targeted for change.

Concerns about financial incentive systems

Although incentive interventions are useful, psychiatrists rarely use them. There are several reasons for this. One relates to familiarity, as few mental health providers are aware of these types of interventions. Second, there is often no method by which providers can be reimbursed for incentives, as they are not covered by Medicaid or private insurers. The Veterans Administration, however, is implementing incentives nationwide in its substance abuse treatment clinics, and many employers use incentives to promote health behaviors-a practice encouraged by the US Affordable Care Act.

Although more information is needed to guide policy, data suggest that incentives are cost-effective.⁹ Novel methods to apply financial incentives exist, such as arranging for direct access to disability payments or partial rebates on health insurance costs contingent upon meeting specific objectively defined goals.

Potential ethical considerations also arise. Of course, caution must be used when reinforcing adherence to medications because some patients may continue to take the medication even when they experience adverse effects. However, there hasn’t been a single adverse event of incentives documented in the context of substance use disorders. The prize-based system’s effects on gambling have been studied extensively, and it does not intensify gambling behaviors. The criticism that external reinforcers undermine internal motivation to change also has little basis in empirical studies of clinical populations.¹⁰

There may be an assumption that mental health patients do not understand or respond to contingencies. However, findings indicate that these interventions are highly effective in patients with severe and persistent mental illness.^11,12

Some clinicians fear that reinforcement interventions will not engender long-term change. Although effect sizes of incentive interventions are clearly larger during the period they are in effect relative to post-treatment, persistent benefits have been seen in a third of incentive studies.¹³ Furthermore, there are no data to support the contention that patients who receive incentives have poorer long-term outcomes than those who do not.

Challenges remain to extending the benefits of incentive interventions, but attaining a period of continuous abstinence is critical for long-term success. Incentive interventions have the largest effect size of any psychosocial treatment for substance use disorders in promoting abstinence.¹⁴

CASE VIGNETTE

For several years, Dr. Jones has been seeing 25-year-old Matt, who has schizophrenia and stimulant and alcohol use disorders. Matt receives a monthly disability payment of about $1000, which he often spends on drugs-leaving little money for other expenses. His parents buy food and necessities. Matt misses about half of his appointments with Dr. Jones, which results in inefficient use of Dr. Jones’s time, along with reimbursement loss. About 2 or 3 times a year, Matt is hospitalized because of medication non-adherence when he is using drugs.

Dr. Jones sees Matt twice a month, an insufficient frequency with which to monitor and reinforce abstinence. Dr. Jones’s clinic, however, can be reimbursed for more frequent urine sample monitoring. Matt’s parents are already spending hundreds of dollars monthly for their son’s living expenses. Dr. Jones holds a meeting with the family and suggests that the parents provide up to $200 a month contingent on their son’s abstinence. To earn these funds, Matt has to provide a negative breath alcohol and negative cocaine urine sample every Monday and Thursday. For his first set of negative samples, he gets $10, and 2 consecutive negative samples earn him $15. Amounts increase by $5 until they reach a cap of $25 after 2 full weeks of negative samples. A missed or positive sample resets earnings to $5 for the next negative. In total, the system costs no more than $200 per month-less than his parents spend now.

Matt’s parents do not give the money directly to their son. Matt earns money in this manner only with Dr. Jones’s oversight. If Matt relapses and spends all his disability income on drugs, his parents agree to provide food only in their home, or to direct him to a soup kitchen. Unearned funds are returned to the parents. Dr. Jones sets up an accounting system and designates a nurse to deliver the intervention on days he does not see Matt.

Matt is initially skeptical of the plan, but he provides negative breath and urine samples at his first session and receives $10 on the spot. Dr. Jones congratulates Matt and reminds him he could earn $15 on Thursday if he remains abstinent. Dr. Jones asks him what he will do with his earnings. Matt says he will go to Subway for lunch, something he can rarely do. He tests negative on Thursday, and the nurse gives him $15, which he spends on a new T-shirt. Matt gradually increases his earnings to the cap of $25.

After about a month of abstinence, Matt fails to attend an appointment. The nurse, and Dr. Jones, try calling him. He does not answer or re-appear until 2 weeks later when he provides a positive sample. Matt receives no earnings, but Dr. Jones reminds him of all he had gained, tangibly and intangibly, when he was abstinent and encourages him to stop using so that he can test negative later that week and resume earning money.

Matt is hungry and disheveled. The staff refers him to a local soup kitchen, but Matt goes to his parents. They remain firm to their commitment to only provide funds contingent on abstinence. They invite Matt for dinner and tell him they welcome him for every meal until his next testing day; they encourage him to take his medications. Matt comes for dinner the next 2 days. He resumes abstinence and maintains it for years-with only occasional slips and no subsequent psychiatric hospitalizations. Since the program began, he rarely misses appointments with Dr. Jones.

This case exemplifies the successful application of financial incentives. Although not all patients have family willing or able to supply funds, this approach can be useful. Collecting and rapidly screening samples twice weekly allows for frequent monitoring and reinforcement of initial abstinence and appropriate implementation of incentive principles. After sustained periods of abstinence were achieved, Dr. Jones eventually reduced the testing and reinforcement frequency.

Acknowledgments-This article is based in part on work supported by National Institutes of Health Grants P50-DA09241, P60-AA03510, R01-HD075630, R01-AA021446, DP3 DK097705, and R01-AA023502.

Disclosures:

Dr. Petry is Professor of Medicine, University of Connecticut Health Center, Farmington, CT. Dr. Petry reports no conflicts of interest concerning the subject matter of this article.

References:

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