Today’s Managing Health Care Costs Number is 12
University of Pennsylvania researchers published a carefully designed study in JAMA this week assessing the efficacy of patient and physician incentives to lower LDL and improve adherence to statin medications. The study was big (1500 patients), well designed, and lost no patients to followup over 15 months. The incentives were meaningful – over $1000 per patient for physicians and patients who participated.
The results are sobering.
There was statistically better adherence (measured by electronic pill bottle caps that track opening) for those patients randomized to both physician and patient incentives. However, this difference was small – and not likely to be clinically significant. The cost was large – if all patients and physicians participating in this research in the group with incentives for physicians and patients and achieved adherence goals, the cost would have been over $2 million. That doesn’t count the considerable administrative costs of the program, including the electronic pill bottle caps, tracking, and incentive fulfillment. On average, this would have led to decreases in LDL of just 12 mg/dl compared to the control group.
The most striking finding to me is the low rate of medication adherence in all groups. Adherence was taking medication as prescribed 80% of the time; only 1 in four of the control group achieved this, and only 4 in 10 with physician and patient incentives were assessed as adherent.
It’s also especially disappointing that patient incentives alone didn’t nudge LDL levels down at all compared to the control group. Patients control whether or not they take their meds – and it would be nice to be able to aim interventions squarely at them rather than at physicians.
We should keep on trying various incentive programs to influence the behavior of patients and physicians. We should measure the results carefully, as Asch and colleagues did here, since real life results are not always what we’d expect. Extrinsic incentives are most likely to work when they are awarded quickly for simple activities (like patients taking a pill), as opposed to when they are awarded later complex behaviors without clearly visible outcomes (like physicians encouraging patient adherence).
For all of human behavior, intrinsic motivation is all important.
Adherence by Group Assignment
LDL Level by Group Assignment 
