Why Smart Pill Bottles and Financial Rewards Don’t Improve Medication Adherence

A study published recently in JAMA Internal Medicine showed financial rewards and connected pill bottles don’t work. One explanation suggests that “other patient concerns about potential adverse effects of these medications, such as impotence or fatigue, were not targeted by this engagement strategy.”


How can a patient engagement strategy not target the patient’s concerns? Isn’t that the very definition of patient engagement? Impotence and fatigue are a big deal to most people. Would an extra $15 a week compel you to take a medication that made you impotent? $150 a week? Would a pulsating pill bottle in your cabinet get you to swallow a pill that made you feel foggy and tired all day?

We can’t incent or remind someone to do something they never agreed to or intended to do. It would be like Amazon pinging you to buy something you would never consider adding to your cart. Amazon nudges you to buy things that you would put in your cart or things you saved to your cart, but never purchased. Why aren’t we as laser-focused on what matters to patients?

When 1/2 of all people prescribed a medication do not adhere to their plan, we have to consider that they never agreed to it or recognized its importance in the first place. They didn’t forget. (Psychologists, myself included, don’t believe in “forgetting.”) Even the most “forgetful” people do not forget to eat or have sex.

You forget what you don’t want to do. Forgetting is a way of saying “no.” Patients don’t say no to their physician’s face, but they say “NO!” en masse when they don’t fill their prescription or fill it but don’t take it. When I wrote a post recently about the importance of welcoming the patient’s resistance to their care plan, some responded that I wasn’t recognizing the dangers of non-compliance. This couldn’t be further from the truth. I am simply not deluded that we can control, coerce, enforce or even educate our patients into compliance. In light of the recent JAMA Internal Medicine article, we need a different approach.

The Paradox

If we let patients say “no” to their treatment plans, they are more likely to say “yes.”

When they say “yes,” they are more committed.

The conclusion: Let them say “no,” if we want better results.

The physician is the expert at prescribing medication; patients are the experts on why they won’t take it.

I have spent my career working with patients who are making decisions that will determine whether they live or die, whether they lose limbs to disease, contract diseases that can kill them or destroy their lives and bodies through addiction. It’s a harrowing drive on a road with hairpin turns.

We clinicians are in the passenger seat no matter what we do. And the driver has never been down this road before.

When I teach residents in psychiatry, I tell them that learning to let patients drive is like training yourself to accelerate into a skid on an icy road. At first, every muscle in your body wants to resist, pull away, brake, as you feel the loss of control when the car slips on the ice. Then, you remember the facts: you are supposed to accelerate into the skid, so you let go off your tight grip on the wheel, you accelerate, you hang in the balance horribly for an instant and then the car rights itself almost effortlessly. And then, you realize you never held the wheel at all, you were in the passenger seat the whole time working with an imaginary set of controls! It takes years of experience and profound discipline to accelerate into these skids with our patients.

How does a patient-driven approach work in practice?

In 15 minute visits, providers need to get right to the point, by saying things like:

Dr. S: Look, I am prescribing this medication because I believe it can help you, but 1/2 of patients don’t end up taking it. So, before I give you this prescription, tell me all the reasons you might not take this medication and how this plan we just made is going to fail.

Patients will be surprised by this. Good! The surprise gets them thinking and engaged. They are being called on as the expert in their own care.

Mr. X: No, I am going to take it. I know I need to.
Dr. S: Some people who take this medication say it affects their sex drive and it makes them feel foggy. What will you do if that happens to you?

Mr. X: Seriously? Well, first, I am going to be very mad at you, Dr. Smith (laughs). No, but I get it, it’s important. I guess I could come back you? I’m not saying I would like it if that happens, I might have to come back to you though if that happens.

Dr. S: Of course you can come back to me. But I can’t promise that I can solve it.

Mr. X: Are there any other options? I’ve heard some people change ____ and they don’t have to take any medication at all.

Dr. S: Yes, we can talk about that and they might reduce the amount of medication you have to take and some of the side effects, but you likely still have to take medicine.

What just happened? The doctor acknowledged the patient was the one behind the wheel, the patient was surprised but intuitively started driving and making decisions and commitments. By letting the patient say no, the doctor let the patient say yes. And the patient’s yes is a critical step to improving adherence. The patient starts making suggestions, problem-solving, and asking for alternatives. This is one interaction that needs to be repeated again and again.

Patients don’t need reminders, extrinsic motivators, or incentives. They need help identifying intrinsic motivations and personal barriers, and they need their internal problem-solving abilities mobilized. All of our well-meaning education, instructions and attempts at coercion are noise from the passenger seat – distracting the driver.

What does this mean for digital health?

Digital health technologies are not doomed, in fact, this study marks a major turning point. We see what doesn’t work and we can move on. Fail fast and learn.

Digital technologies are well-suited to a patient-driven approach. At Vital Score, we have turned a disciplined patient-driven methodology into a codified method of delivering thousands of digital conversations with patients. We call our method Motivational Indexing™ because we capture and categorize what motivates people, we let them navigate a pathway to health, and we learn from the paths they create. Motivational Indexing™ works because it learns from the experts on non-adherence: patients.

We should welcome the news that reminders and incentives don’t work. It turns out the experts in medication adherence are not behavioral economists, physicians (or psychologists!). The experts are patients and we will learn if we listen to them.

Hilary Hatch is Founder and CEO of Vitalscore. 

10 replies »

  1. Thanks for your comments. Maybe the unnecessary meds and the needed meds are connected. The unnecessary meds undermine trust.

    I think you would find some work we did interesting. When we were trying to understand the needs of poly-pharmacy patients for a large health plan, we asked “what would you like to change about your medications?” We found a high percentage of patients responded, “I’d like to know if my medications are working.” There is a vast gap in communication and perhaps an even larger gap patient buy-in.

  2. I have the chills reading this. Would you take the time to elaborate? What conditions and which quality scores force physicians into this predicament?

    As a mental health professional, I have serious doubts about how the PHQ-9 has been shoved into primary care. Instead of “integrating behavioral health into primary care,” the lofty goal, the PHQ-9 seems to just push the prescription of anti-depressants for one of many possible behavioral health issues. A physician leader I met with this week said how quickly screening tools like PHQ-9s get mistaken for diagnostic tools. And so many providers then feel pressured to prescribe. It’s disturbing how good intentions to control quality can lead to overly rigid, impersonal recommendations.

    If you could please write more about this, I think there are many other physicians who would agree with you.

  3. Good piece and dialogue about a serious issue that’s been vexing for years. Considering that an estimate 1/5 to 1/4 of all prescribed medicines may be unnecessary (due to over-prescribing and poly-pharmacy, especially in the elderly), maybe patients are making rational choices, even if they don’t know it. But that’s too glib…because we know millions don’t take NEEDED meds. And so we desperately need to understand why. Thanks Hillary for this piece and your work…even if this blog is promotional of a product and service.

  4. In the same way that you can’t just add curry powder to a dish and expect it to be a gourmet Indian dinner, you can’t just add incentives to a trial and expect an optimal outcome. In fact, we’ve shown that incentives, when combined with other key components of a robust digital engagement program, do improve adherence. While there is no silver bullet to resolve adherence, there are methods and approaches that improve adherence. The challenge we face as digital health professionals is impact and scale. How much can we increase adherence and at what scale?

  5. How about:

    “I’m prescribing this medicine because if I don’t it will affect my quality scores and my income will be reduced. I don’t think that, in your particular case, it will be of any benefit and it very well may cause serious side effects . . . click . . . click .. . . . click . . . next!”

  6. The Design Principles for Managing a Common Pool Resource have been fully validated by Professor Elinor Ostrom (2009 Nobel Prize) and her many colleagues. As an introduction to this realm of knowledge, I would recommend her book “GOVERNING THE COMMONS: The evolution of Institutions for Collective Action” published in 1990. The best example of this within the United States is shown by the preservation of the fresh water aquifer under the city of Los Angeles in California beginning around 1930, WITHOUT the hand of either State or Federal governmental involvement. Its an example, among many, where collaboration and trust ultimately resolved the social dilemmas that were necessary to achieve a vital benefit for the entire metropolitan community.

  7. Focusing on your statement: ” Compliance with medication use is easily the most difficult and poorly recognizable factor leading to unstable health.”

    If this is true, then shouldn’t we pause before putting patients on medication at all or on complex regimens? Really pause and wonder, “Is this going to work out well in the end?” and maybe share that concern with the patient? As in, “this is only going to work if you take it, so I really need you as my partner in this decision.”

    If compliance is in your words “a leading factor in unstable health”, are we inadvertently creating unstable health when we know many and sometimes MOST patients won’t follow a certain regimen? If we are serious about improving adherence rates, we have to consider whether we are prescribing without adequate evidence that the treatment will be successful. We need real-world trials where the medication’s efficacy INCLUDES the patients who didn’t take it. If only 50% of patients end up taking it, the drug’s effectiveness rate is immediately halved and would be reported as such.

    Evidation is a company that might actually break new ground in this area through new models of research that could reach much larger populations in real-world studies. Imagine the positive shift in pharm.’s incentive structure if efficacy in a controlled situation and real-world success rates were one and the same! Many researchers are interested in changing research models to reflect real world implementation of an intervention.

    Thank you for your response!

  8. The VA folks, probably most clearly, studied the compliance with the use of medications for epilepsy about 30 years ago. A single medication taken daily, even under ideal circumstances, can reach 95% but twice a day drops to 85%, three times a day drops to 65% and four times a day drops to 50% or less. It becomes all the more strange when mood altering meds or warfarin are included AND a serious contributor to unstable HEALTH when the total number of meds, taken at least once a day, passes five-ten or more. But, for a Primary Physician, these issues become their bread (? crackers ) and butter (? margarine ). Compliance with medication use is easily the most difficult and poorly recognizable factor leading to unstable health.

  9. I think alert fatigue and basic human psychology have something to do with these problems

    In an ideal world a smart pill bottle would be the perfect answer.

    We would live utopian lives with our smart pill bottles and achieve everlasting life — or at least 99.5% compliance . In the real world we have some many beeps and pop ups and alerts going on at once that our brains tune these things out …

    Our smart bottles have to compete with our digital calendars, our electronic address books, or automated refrigerators and our Amazon shopping task list.

    The smart pill bottle has little if any hope.

    Incentives are another story, for another time.

    The short version?

    They don’t work very well, if at all.

    / j

  10. Don’t forget the two big motivators: operant conditioning and fear of dying.

    Every day we must all have a hundred different messages sent by our nerve fibers to our brains and the same numbers sent by our brains to other parts of our brains observing the former action. [hey! why is my right ankle hurting just as I stepped out of the car?] If we are taking pills and some of their side effects, or what we think are their side effects, happen to be the same as these spontaneous random symptoms we are having, and especially if these are associated on several different days, we are going to think the pills did it..,simply by operant conditioning. And we may stop our meds as an experiment to see.

    Same theory goes for symptoms we think are caused by the weather or having wife yelling too much, etc.. Move to Arizona or get divorced?

    And secondly….We will always remember to take our pills if our doc says they are to prevent our dying….and especially if there are obvious symptoms of the death process which come and go according to our pill intake….like shortness of breath or tachycardia or syncope. Duh, we say, better follow doctor orders!