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The American Journal of Managed Care June 2017
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Patients' Views of a Behavioral Intervention Including Financial Incentives
Judy A. Shea, PhD; Aderinola Adejare, BA; Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD; Darra Finnerty, MPH; Karen Hoffer, BS; Thomas Isaac, MD, MPH, MBA; Meredith Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and David A. Asch, MD, MBA
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Jennifer L. Cerully, PhD; Steven C. Martino, PhD; Lise Rybowski, MBA; Melissa L. Finucane, PhD; Rachel Grob, PhD; Andrew M. Parker, PhD; Mark Schlesinger, PhD; Dale Shaller, MPA; and Grant Martsolf, PhD, MPH, RN
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Hannah L. Semigran, BA; Rebecca Gourevitch, MS; Anna D. Sinaiko, PhD; David Cowling, PhD; and Ateev Mehrotra, MD, MPH
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Patients' Views of a Behavioral Intervention Including Financial Incentives

Judy A. Shea, PhD; Aderinola Adejare, BA; Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD; Darra Finnerty, MPH; Karen Hoffer, BS; Thomas Isaac, MD, MPH, MBA; Meredith Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and David A. Asch, MD, MBA
Patients who enrolled in a trial to lower low-density lipoprotein cholesterol spoke positively of the multifaceted intervention: pillbox monitoring and financial incentives were socially acceptable.
Objectives: Clinical trials are increasingly testing the effectiveness of paying patients’ financial incentives for achieving desired clinical outcomes. Some researchers and providers are concerned that patient financial incentives will harm the doctor–patient relationship. How patients feel about these approaches, and these trials, is largely unknown. This study examined patients’ perceptions of a compound behavioral and financial incentive intervention used in a large multicenter trial to lower low-density lipoprotein cholesterol (LDL-C), including their perceptions of benefits and challenges and the study’s effect on patients’ relationship with their primary care physicians (PCPs). 

Study Design: Semi-structured telephone interviews with patients post intervention. 
Methods: PCPs from 3 primary care practices in the northeastern United States were randomized to 1 of 4 arms: physician financial incentives, patient financial incentives, shared incentives between physicians and patients, and a control arm. Within each arm, 10 high, 10 medium, and 10 low performers in LDL-C reduction were interviewed. Interviews targeted reasons for enrolling in the study, the specific intervention elements that helped them reach the goal (incentives, engagement, monitoring), challenges faced in reducing cholesterol, and the impact of study participation on their relationship with their PCP.
Results: Patients reported positive experiences with the study: 65% described personal changes to improve health and 61% reported increased awareness. Views about financial incentives varied: 71% clearly found them motivating and 36% claimed they made no difference. Patients noted that changing lifestyle (36%) and diet (65%) was difficult. Patients who substantially lowered their LDL-C revealed themes similar to those who did not. 
Conclusions: Overall, behavioral interventions with financial incentives appear to be socially acceptable to patients who participate in them. Both adherence monitoring and financial incentives were well received, with little effect on the physician-patient relationship.
Takeaway Points
Patients who enrolled in a trial to lower low-density lipoprotein cholesterol (LDL-C)—one that included financial incentives to patients or to physicians or were shared between patients and physicians—spoke positively of the multifaceted intervention. One-on-one interviews revealed:  
  • Wireless pillboxes for monitoring served as a reminder to take medications. 
  • Blood draws every 3 months were reinforcing and informative. 
  • Financial incentives were appreciated but not viewed as particularly motivating. 
  • Patients who substantially lowered their LDL-C revealed themes similar to those who did not. 
  • Financial incentives were rarely discussed; they did not disrupt the patient–physician relationship. 
  • Overall, financial incentives appear to be effective and socially acceptable.
Patient nonadherence to recommended treatment is a barrier to improving outcomes, but the use of financial incentives to overcome this barrier is increasing.1,2 Eighty-five percent of large employers use financial incentives to improve health behaviors in realms ranging from smoking and other addictions to weight control and medication adherence.3-5 In a recent randomized controlled trial focused on reducing low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk or established cardiovascular disease, incentives based on principles of behavioral economics were used to motivate both patients and providers.6 In the parent study, 340 primary care physicians (PCPs) from 3 health systems and about 15,030 of their patients were enrolled into a 4-arm trial to test alternative incentive strategies to lower LDL-C. PCPs were randomized to 1 of 4 arms: physician financial incentives, patient financial incentives, shared incentives between physicians and patients, and a control arm. Progress was monitored through quarterly LDL checks and medication adherence via pill bottle opening. The primary outcome was LDL reduction over 12 months. The intervention was a compound of multiple behavioral economic strategies.

The main trial showed significant benefits for those in the shared incentive arm, but the effectiveness of the intervention ranged across individuals. The purpose of this current study was to investigate patients’ perceptions of the intervention and learn from their stories of how the intervention affected their behaviors. The specific objectives were to investigate patients’ perceptions of financial incentives and of multiple components of the behavioral intervention, including overall thoughts about benefits and challenges and how being in the study affected their relationship with their physician. We were particularly interested in how perspectives differed between patients who succeeded in lowering their LDL-C and those who did not. Secondarily, we examined if narratives about incentives differed among patients randomized to different arms of the study.


Overview/Summary of the Underlying Intervention

The protocol for the main trial is summarized briefly here.6 A total of 1503 patients with high cardiovascular risk or established cardiovascular disease were enrolled; they were nested within 340 PCPs from the University of Pennsylvania (Penn), Geisinger Health System (GHS), and Harvard Vanguard Medical Associates (HVMA). The study compared 4 approaches to reduce LDL-C: physician incentives, patient incentives, shared physician–patient incentives, or control (no financial incentive or regular feedback). For the patient and physician incentive arms, the maximum expected value of the incentive was $1024 per enrolled patient who met LDL-C goals. PCPs and patients in the shared arm shared those possible financial incentives. Patients also received surveys, quarterly LDL-C checks, and wireless pill bottles (Vitality GlowCaps) which were used to store their cholesterol-lowering medication and electronically monitor bottle openings.


In this study, semi-structured telephone interviews were conducted with patients post intervention from February 2014 through July 2014. The methods and script were approved by the University of Pennsylvania Institutional Review Board.


Purposive targeted sampling was used. Within each of the 4 arms, the goal was to interview 10 high, 10 medium, and 10 low performers in LDL-C reduction, stratified across the 3 study sites. Within each of the 12 cells, 5 patients were targeted from GHS, 4 from Penn, and 1 from HVMA, proportional to the total patient sample at each site. Patients were interviewed in multiple waves, formed as groups of patients completed their 15-month visits. The final number of interviews is shown in Table 1. For each wave of completed data, usually for 60 to 80 patients, the mean change in LDL-C (baseline to 12-month) was calculated, then sorted by site within arms. Within each arm, the distribution was inspected and the 4 to 5 patients with the most improved, most worsened, and least changed LDL-C were prioritized, choosing only 1 patient per clinical site per wave. Therefore, “high” and “low” do not have a constant cut-off. However, across the selection waves, median changes in LDL-C among targeted patients were similar.


The interview script was developed by a study team of health economists, physicians, and qualitative researchers. They drew on the literature and their expertise to develop conversational questions related to the study elements and the potential impact of behavioral interventions. Initial scripts were piloted and revised as necessary prior to the study and were constant for the duration of active interviewing. Revisions were based on queries about unclear questions, and the order of the questions was changed to improve flow. Pilot interviews are not included in the analyses. Key questions targeted reasons for enrolling in the study, parts of the study that helped them reach the goal (surveys, wireless pill bottle, cholesterol check every 3 months, and incentives, for patients in arms that received them), challenges faced in reducing cholesterol, and the effect of the study on their relationship with their doctor.

Interviews and Coding

Two trained interviewers conducted the interviews. Recordings of the interviews were transcribed by an independent transcription agency. De-identified transcripts were imported into NVivo version 10 (QSR International Pty Ltd) for coding and analysis.

Four trained coders analyzed the data using elements from grounded theory. The team first identified broad themes based on the first 6 transcripts and then applied open codes to the transcripts. The initial set of codes was tested on each subsequent interview transcript to refine the codebook. Codes were revised iteratively by constant comparison between and within transcripts, and more content-driven axial codes were applied. A final coding scheme was established and applied to all transcripts. In a post hoc analysis, the comments about financial incentives were grouped by arm, blinded, and reviewed by the senior author, with a goal of understanding the main trial results. Inter-rater reliability was assessed on samples exceeding 20% of transcripts. The research team met weekly to resolve discrepancies via consensus.

In the following section, results are organized around the major research questions, examining perceived benefits and facilitators of study enrollment and components, barriers to study participation and meeting goals, and how study participation affected their relationships with their doctors. Results focus on themes mentioned by more than 20% of the sample. The median kappa was 0.92, with a range of 0.64 to 1.0.


A total of 110 of 120 planned interviews were completed (Table 1). They came from a targeted list of 163 patients, representing a minimum 67.5% response rate; 9 patients refused and the remainder were not reached prior to saturation. Patients providing interviews were demographically and clinically similar to those in the parent trial (Table 2).

Prevalent themes are presented in italics, with quotations summarized in the eAppendix (available at There were few differences between patients whose LDL-C improved greatly and those who did not improve. Similarly, meaningful differences among study arms were not prevalent. When substantial differences were discovered, they are noted at the end of each section.

Reasons for Joining

Patients expressed a range of reasons for joining the study. First, the credibility of a doctor’s recommendation to join the study was a motivating factor for 40 (36%) patients. Second, 34 (31%) patients stated that they joined the study with the hope of finding a solution to their high cholesterol. A third reason for joining was increasing awareness and knowledge (n = 30; 27%). Other relatively common motivators were financial gains (n = 27; 25%), including free and more frequent monitoring, and the benevolence of helping with research (n = 25; 23%). The subgroup of interviewees whose LDL-C worsened gave more responses to this question, but the nature of what they said was not qualitatively different. The subgroup whose LDL-C improved often mentioned enrolling to facilitate healthy behaviors and to learn more about cholesterol issues.

Benefits and Facilitators: General

Patients offered a wide range of responses to queries about the benefits of enrolling in the study. Seventy-one (65%) patients described personal changes that affected the way they manage their health and their understanding of health-related topics. Commonly referenced topics were diet choice and exercise regimens. The study made patients think more about the foods that they were eating and the necessity of changing eating habits. These changes included reading labels before buying food, shopping for healthier food options, and portion control. The study also inspired patients to engage in more exercise. Some learned that they were able to control their cholesterol with diet and exercise and others learned the necessity of medication in controlling their cholesterol.

Just over half (n = 61; 55%) of the patients spoke of appreciating the increased awareness and information. Several patients explained that being in the study made them more aware of the severity of their health condition; 34 (31%) specifically mentioned improved health. The subgroup of interviewees whose LDL-C got better more often gave examples of how they changed a health behavior and more frequently spoke of more consistent use of medication.

Benefits and Facilitators: Intervention Components

Three-month visits. More than half (n = 69; 63%) of the patients mentioned the benefits of receiving blood test results every 3 months; they liked the awareness, and tracking enabled them to make appropriate adjustments as well as understand how medication use affected their cholesterol levels. It was also satisfying to see how diet and exercise changes affected their cholesterol. They also appreciated the increased access to services (n = 48; 44%) and did not find the visits inconvenient (n = 47; 43%)

Wireless medication adherence devices. Patients generally agreed that the wireless devices were a facilitator in lowering their cholesterol. The devices served as a reminder to take medication (n = 39; 35%). Many thought the devices were easy to use and expected to continue to use them after the conclusion of the study. They liked being monitored (n = 33; 30%)

Surveys. Patients did not say much about the surveys. The most prevalent comment was about increased awareness (n = 40; 36%). The surveys provided a friendly reminder of the appropriate steps that patients should be taking to keep their cholesterol under control.

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