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Should patients be paid to take their treatment?

Ensuring that patients adhere to their prescribed treatments is one of the most significant challenges in healthcare today. Non-adherence can lead to worsened health outcomes, increased hospitalizations, and higher healthcare costs1. A growing body of evidence suggests that motivating patients to follow their treatments involves a complex interplay of psychological factors2. Among the strategies proposed, monetary incentives—an example of extrinsic motivation—have sparked both interest and debate3. However, research suggests the need to focus more on fostering intrinsic motivation4. In a study involving patients undergoing antiretroviral therapy for HIV/AIDS, those with optimal adherence appeared to attribute the majority of their treatment behaviors to intrinsic motivation rather than extrinsic motivation5.

Understanding Motivation: Intrinsic vs. Extrinsic

Motivation can be classified into two primary types:

  • Extrinsic Motivation: This arises from external rewards or pressures. For example, financial incentives, discounts, or gift cards provided for taking medication or attending medical appointments6-8.
  • Intrinsic Motivation: This is driven by internal factors such as personal values, a sense of accomplishment, or the desire to lead a healthier life9.

The Problem with Extrinsic Motivation

While extrinsic rewards may lead to immediate behavior change, their impact is often temporary. Studies have shown that once the reward is removed, adherence typically declines, sometimes to levels lower than before the intervention. This phenomenon, known as the overjustification effect, occurs when external rewards undermine intrinsic motivation by shifting focus away from internal values6.

Evidence Supporting the Limitations of Extrinsic Motivation

  • Short-Term Compliance: A study examined the impact of financial incentives on medication adherence among patients with hypertension. It found a modest improvement during the reward period, but adherence dropped once the incentives ceased7.
  • Undermining Long-Term Commitment: Research in behavioral science highlights that extrinsic rewards can create dependency, where individuals begin to associate the desired behavior (e.g., taking medication) exclusively with the reward. Once the incentive is removed, patients may no longer feel motivated to maintain the behavior6,8.
  • Counterproductive Outcomes: In some cases, monetary rewards can lead to a transactional view of health. Patients might begin to question the value of behaviors that are not externally rewarded, potentially decreasing adherence in areas where incentives are absent6,7.

The Case for Fostering Intrinsic Motivation

Building intrinsic motivation is a more sustainable and empowering approach. When patients understand the value of their treatment and feel in control of their health, they are more likely to adhere to recommendations over the long term9.

Strategies to Enhance Intrinsic Motivation

  • Education and Shared Decision-Making: When patients understand the “why” behind their treatment and are actively involved in decision-making, they are more likely to adhere to their regimen10.
  • Supportive Healthcare Relationships: Trust and communication between healthcare providers and patients are critical. Providers who listen, empathize, and offer encouragement can strengthen intrinsic motivation by affirming the patient’s role in their own care11.
  • Behavioral Nudges: Simple, non-monetary nudges like reminders, positive reinforcement, or framing adherence as part of a broader goal (e.g., being healthy for loved ones) can be effective12,13. Behavioral economics research suggests that such low-cost interventions can impact adherence without undermining intrinsic motivation14.
  • Creating Meaningful Goals: Helping patients connect their health behaviors to personal values—such as being able to play with their grandchildren or achieve professional aspirations—can create a powerful internal drive15,16.

A Balanced Approach

While extrinsic motivators, such as financial incentives, may play a limited role in kickstarting behavior change for certain populations, they should never replace efforts to cultivate intrinsic motivation. A well-rounded strategy should combine:

  • Initial external motivators for immediate adherence, if necessary.
  • A robust framework to transition patients toward intrinsic motivation through education, empowerment, and ongoing support17.

Conclusion

Paying patients to take their treatment may seem like a quick fix for a complex issue, but it is not a sustainable solution. Extrinsic motivation, while useful in the short term, risks undermining the very behaviors it seeks to promote. Healthcare systems and providers should focus on fostering intrinsic motivation by empowering patients, building trust, and aligning treatments with patients’ personal values18. Such efforts not only improve adherence but also enhance the patient experience and overall health outcomes.

By reallocating resources from financial incentives to intrinsic motivation-building strategies, healthcare systems can achieve more meaningful, lasting results.

References

  1. Khan R, Socha-Dietrich K. Investing in medication adherence improves health outcomes and health system efficiency, OECD, 2018 https://www.oecd.org/en/publications/investing-in-medication-adherence-improves-health-outcomes-and-health-system-efficiency_8178962c-en.html
  2. Choudry M, Ganti L. Exploration of the Motivational Factors that Influence the Maintenance of Health. Health Psychol Res. 2024 Mar 24;12:115356.
  3. 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 Aug 1;177(8):1093-1101. 
  4. Palacio A, Garay D, Langer B, Taylor J, Wood BA, Tamariz L. Motivational Interviewing Improves Medication Adherence: a Systematic Review and Meta-analysis. J Gen Intern Med. 2016 Aug;31(8):929-40.
  5. Houston E, McKirnan DJ, Cervone D, Johnson MS, Sandfort TG. Assessing treatment motivation among patients receiving antiretroviral therapy: a multidimensional approach. Psychol Health. 2012;27(6):674-87.
  6. Deci EL, Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychol Bull. 1999 Nov;125(6):627-68; discussion 692-700.
  7. Zheng L, Liu S, Jiao Y, Wu Y, Wang Y, Yu Z, et al. Effect of Financial Incentives on Hypertension Control: A Multicenter Randomized Controlled Trial in China. Hypertension. 2022 Oct;79(10):2202-2211. doi: 10.1161/HYPERTENSIONAHA.122.19568.
  8. Thirumurthy H, Asch DA, Volpp KG. The Uncertain Effect of Financial Incentives to Improve Health Behaviors. JAMA. 2019 Apr 16;321(15):1451-1452.
  9. What is intrinsic motivation? Definition and examples. https://www.betterup.com/blog/intrinsic-motivation. Last accessed 04/03/2025
  10. Ward J, Kalsi D, Barnett N, Fulford BK, Handa A. Shared decision making in chronic medication use: Scenarios depicting exemplary care. Res Social Adm Pharm. 2020 Jan;16(1):108-110.
  11. Sharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023 Aug 22;23(1):886.
  12. Möllenkamp M, Zeppernick M, Schreyögg J. The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review. Health Policy. 2019 Dec;123(12):1199-1209.
  13. Lauffenburger JC, Yom-Tov E, Keller PA, et al. The impact of using reinforcement learning to personalize communication on medication adherence: findings from the REINFORCE trial. NPJ Digit Med. 2024 Feb 19;7(1):39. doi: 10.1038/s41746-024-01028-5.
  14. Liu Y, Yang Y, Bai X, Chen Y, Mo L. Do Immediate External Rewards Really Enhance Intrinsic Motivation? Front Psychol. 2022 May 16;13:853879.
  15. Bischof G, Bischof A, Rumpf HJ. Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice. Dtsch Arztebl Int. 2021 Feb 19;118(7):109-115.
  16. Hall K. Motivational interviewing techniques, RACGP, https://www.racgp.org.au/FSDEDEV/media/documents/Publications/AFP-Sep-2012-Motivational-interviewing-techniques.pdf – last accessed 08/12/2024
  17. Abdul Rahim MI, Thomas RH. Gamification of Medication Adherence in Epilepsy. Seizure. 2017 Nov;52:11-14.
  18. Matthews JA, Matthews S, Faries MD, Wolever RQ. Supporting Sustainable Health Behavior Change: The Whole is Greater Than the Sum of Its Parts. Mayo Clin Proc Innov Qual Outcomes. 2024 May 18;8(3):263-275. doi: 10.1016/j.mayocpiqo.2023.10.002.

This article was written with the assistance of generative AI technology and reviewed for accuracy.