To some, nothing talks as loud as cold cash

Some health care providers disagree

Even though the practice makes some health care providers squirm, sometimes nothing beats cold hard cash for promoting adherence, says Jennifer Lorvick, TB project director of Urban Health Studies at the University of California, San Francisco (UCSF).

Lorvick is in charge of a study at UCSF that compares cash incentives, directly observed preventive therapy (DOPT), and a "standard care" approach where patients simply show up at a clinic once a month.

"So far, we’re finding that — surprise, surprise! — cash incentives work best," says Lorvick. Because all of her patients are injecting drug users (IDUs) recruited from the streets, no one denies that the patients may not be using their twice-weekly $10 incentive payments to buy, for example, a pair of warm socks, says Lorvick.

Yet there’s also no doubt that the cash payments work. So far, adherence rates among the IDUs who collect cash in exchange for downing their isoniazid are running better than 70%, says Lorvick. By comparison, only 50% of patients who get DOPT are adherent — "and that’s with a good outreach worker," she adds.

Among patients in the "standard care" arm of her study, only one or two have bothered to show up for a single clinic visit, she says.

"There really are legitimate issues about cash incentives," Lorvick says. "But one thing I don’t have any problem with is whether they spend the money on drugs. What they do with their money is their business, just like what I do with my money is my business."

To Lorvick, the real issue is whether paying cash to get people to take medicine constitutes a form of behavioral coercion: "Am I forcing someone to do something they might not otherwise choose to do? Is that appropriate?"

Despite the ethical issues it brings up, cash incentives actually can be cheaper than other methods of boosting adherence, Lovick says. At $10 apiece for 52 doses of INH her project provides, the cost (excluding the cost of medication) is $520; the only other expenses are rental fees for the community site where the medicine is dispensed, plus labor costs.

That last category is where the real savings come in, Lorvick says, since it takes staff only about three hours, twice a week, to do their jobs. Paying an outreach worker to spend the day hunting down addicts in crack houses or on street corners is much more time- and labor-intensive, she says.

Make the cash accessible

Besides the obvious lure of cash, one reason Lorvick thinks the cash incentives work well is because she has made it easy and convenient for her IDUs to collect the money. "The field site needs to be within walking distance," she says. The hours need to be convenient, too. "We also have a three-hour period" — she’s chosen Tuesday and Friday from noon until 3 p.m. — "where people can come in, so they don’t have to be at a certain place at a certain time."

Numbers from the current study look much like data from an earlier smaller study Lorvick conducted that also tested cash incentives. In the earlier project, 24 out of 27 IDUs (who again were paid $10 per visit) completed their isoniazid prophylaxis, she says.

A second project in San Francisco that uses smaller cash incentives has also produced good results; but in this case, the lesson is not quite so clearly drawn as in Lorvick’s intervention.

In a project that targets residents of homeless shelters, researchers at another branch of UCSF are testing $5 cash incentives against $5 "treats" — either grocery-store coupons or fast-food vouchers. Both cash and "treat" interventions are being compared against standard care.

So far, treats and cash are working well, with adherence rates of better than 85% in both, says Jacqueline Tulsky, MD, assistant clinical professor of medicine at UCSF. "Frankly, we were surprised," Tulsky says. "I’d hypothesized that cash would work better. Perhaps we’ll find a definable group — people who get their meals delivered, for example, and who don’t need food coupons — for whom cash works better."

Tulsky also thinks that adherence rates were boosted because the project’s site was thoughtfully located. Along with being within walking distance for most of the subjects, the community-based organization where the project is located was chosen because it is "neutral" — that is, not affiliated with any health care facility, she says.

"Poor people often get a negative feeling about clinics and hospitals, and we wanted to make sure we had subtracted that factor out of it," she says.

Perhaps the treats vs. cash study simply shows that consistency and convenience are important, says Tulsky. "Maybe it doesn’t really matter so much what you give, as that you give," she says. She’d like to switch patients from treats to cash, and vice versa, just to see whether that made any difference in adherence, she adds.

In the real world, using cash incentives takes a bit of finesse, Lorvick adds. "It’s easier to do this in a research context than in a clinical context," she says. For one thing, handing out cash payments can be awkward if not all patients are getting them. (Restricting a cash-incentives program to certain hours in a satellite clinic can help keep cash and non-cash groups separate, Lorvick says.)

Despite the potential problems, cash incentives "can be applicable," Lorvick says. "I think they’re definitely worth trying."