A groundbreaking study presented at the American Heart Association’s Scientific Sessions 2025 has provided new insights into the complexities of medication adherence among patients with high blood pressure. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) involved 400 adults diagnosed with hypertension, primarily from underserved communities in New York City. This investigation addressed a persistent challenge in cardiovascular care: improving consistent medication use to reduce the risk of heart attacks and strokes.
The BETTER-BP trial employed innovative behavioral economic strategies, including daily monetary incentives, to motivate patients to take their prescribed antihypertensive medications. Participants were divided into two groups; one group was offered daily chances to win cash prizes ranging from $5 to $50, contingent upon evidence of medication adherence measured through electronic pill bottle openings. The control group received no financial incentives or adherence reminders. This approach sought to objectively verify medication consumption habits beyond self-reporting, utilizing digital pill bottles capable of tracking real-time usage.
Over the six months in which the rewards were available, the impact on medication adherence was profound. Data revealed that participants exposed to financial incentives were twice as likely to engage in consistent medication-taking behavior compared to those without rewards. Specifically, 71% of individuals in the incentivized group opened their medication bottles at least 80% of the days, a striking improvement over the 34% adherence rate in the control cohort. These findings underscore the potential power of financial motivation to alter health behaviors in populations that struggle with medication routines.
However, the study also unveiled a paradox. Despite the marked increase in consistent medication access, the improvements in blood pressure control were statistically indistinguishable between the two groups. Both cohorts experienced comparable reductions in systolic blood pressure after six months—an average of 6.7 mm Hg in the incentive group versus 5.8 mm Hg in the control group. This outcome challenges conventional expectations that higher adherence directly corresponds to better clinical outcomes and suggests that medication adherence alone may not fully account for blood pressure modulation.
Several hypotheses may explain this discrepancy. One consideration is the limitation inherent to electronic pill bottle monitoring—opening the bottle does not guarantee ingestion of the medication. Additionally, participants often managed multiple antihypertensive drugs, yet monitoring was restricted to a single medication per individual, potentially missing subtle deviations in overall therapeutic regimens. The standardized office-based blood pressure measurements taken at discrete intervals, rather than frequent home readings, may also have constrained the sensitivity to detect nuanced clinical changes stemming from adherence.
An equally important observation was the regression of adherence once the financial incentives were withdrawn after the six-month reward period. The participants’ behaviors reverted to baseline patterns of non-adherence, highlighting the transient nature of behavior modification driven solely by extrinsic motivators like cash rewards. This relapse indicates that while financial stimuli can jump-start adherence, they may not foster sustainable lifestyle changes necessary for long-term hypertension management.
Researchers emphasize that these findings illuminate the multifaceted challenges of chronic disease management in socioeconomically vulnerable populations. The study cohort predominantly consisted of Medicaid recipients or uninsured individuals, groups historically burdened with higher rates of uncontrolled hypertension and poorer health outcomes. The interplay of social determinants, economic instability, and healthcare access complicates adherence interventions, suggesting that financial incentives must be part of a broader, integrative approach.
The implications of the BETTER-BP trial extend beyond hypertension care. They offer a vital perspective on the limits and possibilities of behavioral economics in clinical practice. While monetary rewards can effectively shift immediate patient behaviors, the translation to meaningful physiological improvements is not guaranteed. This underscores the need for comprehensive patient support systems that encompass medication adherence, lifestyle modifications, psychosocial interventions, and continuous monitoring.
Moreover, the investigation calls attention to the methodology in adherence research. Reliance on technological proxies for medication intake, such as pill bottle openings, demands cautious interpretation. Future studies incorporating biochemical verification, continuous ambulatory blood pressure measurements, and multifaceted adherence assessments could unravel the complexities observed in this trial.
The study also sparks critical discussions about healthcare policy and resource allocation. Implementing daily financial rewards at a population level entails substantial costs and logistical considerations. Yet, with no lasting blood pressure benefit observed, the value of such incentive programs requires rigorous evaluation against alternative strategies to enhance cardiovascular health equity.
While the preliminary findings reported at this major scientific forum remain under peer review, they provide an essential narrative about the unmet needs in hypertension management. They reveal that increasing medication adherence through financial incentives is achievable but insufficient as a standalone intervention. Effective hypertension control likely demands integrated, patient-centered solutions addressing behavioral, clinical, and social dimensions of health.
John Dodson, M.D., the principal investigator and an associate professor at NYU Grossman School of Medicine, articulates the nuanced challenge: “Improving medication adherence is more complex than previously understood. We must recognize that behavior change driven by external rewards may not endure without deeper engagement and tailored support.” His reflections resonate as the medical community strives to reduce cardiovascular disease burden while confronting the reality of human behavior and system-level barriers.
In closing, the BETTER-BP study underscores a critical lesson in cardiovascular care innovation: change in patient behavior is necessary but not sufficient for improved health outcomes. Future research must explore combinations of financial incentives, patient education, healthcare navigation, and personalized medicine to genuinely transform hypertension management and, by extension, save lives on a broader scale.
Subject of Research: Medication adherence and blood pressure control in adults with hypertension using financial incentives.
Article Title: Behavioral Economics Trial Shows Financial Incentives Double Medication Adherence but Do Not Improve Blood Pressure Outcomes.
News Publication Date: November 9, 2025.
Web References:
- American Heart Association Scientific Sessions 2025: https://professional.heart.org/en/meetings/scientific-sessions
- 2025 High Blood Pressure Guideline: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001356
- American Heart Association Health Information on High Blood Pressure: https://www.heart.org/en/health-topics/high-blood-pressure
References: To be published in the peer-reviewed scientific journal JACC.
Keywords: Blood pressure, Hypertension, Medication adherence, Behavioral economics, Financial incentives, Cardiovascular risk, Health disparities, Medicaid, Electronic monitoring.
