Incentives and Equity: A Randomized Controlled Trial to Improve Glycemic Control in Socioeconomically Disadvantaged Patients With Diabetes

PURPOSE Despite availability of effective diabetes medications, 27% of Israeli patients did not reach glycemic control goals in 2019. Financial hardship markedly impacts diabetes management. The American Diabetes Association recommends financial incentive initiatives as part of quality improvement programs. We investigated the impact of a conditional reduction in medication out-of-pocket costs vs standard payment on glycemic control. METHODS A total of 186 patients with uncontrolled type 2 diabetes were recruited from neighborhoods having low socioeconomic status and randomly assigned to an intervention group or a control group. Patients in the intervention group were offered a discount on drug expenses (up to 600 new Israeli shekels or US $156, distributed through vouchers redeemable at pharmacies) that was conditional on improved glycemic control. Patients in the control group paid for their medications as usual. RESULTS At baseline, study participants had a mean glycated hemoglobin (HbA_1c) level of 9.1%. The mean reduction in HbA_1c level at 6 months in per protocol analysis was 1.4% (95% CI, 1.1%-1.7%) in the intervention group and 0.7% (95% CI, 0.3%-1.0%) in the control group (P <.001). Multivariate linear regression analysis also demonstrated a significant difference in HbA_1c reduction between groups (difference = 0.7%; 95% CI, 0.3%-1.2%; P = .001) after controlling for age, sex, baseline HbA_1c level, body mass index, societal sec-tor, income, education, and diabetes duration. CONCLUSIONS Financial incentives have the potential to enhance diabetes control in populations having low socioeconomic status and could be integrated into health plans as an optional program for patients with chronic disease in disadvantaged areas.