In February 2025, WCG and Mural Health held a joint webinar aimed at tackling ambiguity and open questions about what is allowed and recommended in paying clinical research participants. In response to an overwhelming amount of questions shared before and during the session, we developed a series of blogs offering a deeper understanding of the nuances of clinical trial payments.

In Part 1 of the series, we explored the ethics of clinical trial payments, highlighting the difference between coercion and undue influence, and why fully reimbursing participants is both critical and ethical. We also broke down the main types of payments (reimbursements, compensation, and stipends) and emphasized the importance of transparency, fairness, and making participants financially whole.

Part 2 offers a deeper dive on clinical trial payment types and amounts - what expenses can be covered, how much should be provided, and what methods of payment are best to offer. If you would like to learn more on this topic, or how Mural Health can support your next trial please get in touch with us at sales@muralhealth.com.

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Key Principals: Clinical Trial Payment Types and Amounts

When thinking of payment types in clinical trials, we must first note that not all payments are the same. As covered in Part 1, there are three primary types of payments: Reimbursements (covering specific out-of-pocket expenses), Compensation (covering time, effort, inconvenience, missed work, etc.), and Stipends (a flat amount for all expenses, including time and effort, childcare, and compensation for study specific activities).

As previously mentioned, the guiding principle for labeling and quantifying payments should be making participants whole. Since Reimbursements are not considered taxable income, it is important to label all expenses that can be considered as reimbursements, as such. Reimbursements include travel and lodging expenses, meals and incidental expenses, mileage, parking, WiFi, and cellular service, when used for trial needs.

Then, Compensation and Stipends should be considered for all other expenses that are not recognized as Reimbursements for tax reasons, but still involve trial related expenses for the participant (such as dependent care or time and effort). Amounts provided should cover the incurred participant expense as much as possible within budgetary and operational limitations.

In terms of payment method selection, the best way to think about this is - what payment method will have no cost for the participant, the shortest time to receive payment, and the easiest user experience? In this regard, platforms that allow for direct payment of expenses (at no out of pocket to participants) provide an optimal solution, while digital payment methods are the next best alternative for participants who use them. Other, more traditional payment methods (such as checks, prepaid cards, direct deposits and gift cards) all have their advantages and disadvantages, as detailed below.

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A Q&A with WCG and Mural Health

How do you determine what is the right amount to pay participants?

There’s no simple answer - it’s a balance. Payments need to support recruitment and retention, stay within budget, and be manageable to administer. But above all, they should be fair to participants.

A good starting point is ensuring participants are made whole, which means full reimbursement for out-of-pocket, trial related expenses. It’s something we as an industry still don’t get right often enough, and improving there would make a big difference, both in fairness and in eliminating confusion around taxes or out-of-pocket costs.

When it comes to compensating time and effort, the best approach is to use common sense as to what might be excessive, and to tie payments to the level of participation and time spent. Completion of a quick survey, for example, might warrant a nominal compensation, while a multi-hour visit with procedures calls for more. The key is asking: “Does this feel reasonable and appropriate based on my own experience”?.

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How should a study cover costs beyond travel and meals, such as childcare, pet care, lost wages for required visits, or standard medical care not covered by a participant’s insurance?

Each of these should be treated separately:

• Caregiving needs associated with the trial, such as childcare or pet care, have associated receipts that can be provided to substantiate the expense and receive compensation in line with the expense. It should be noted that these are classified by the IRS as taxable income (not reimbursements), which is important for considering the tax implication of payments (more on this in part 3 of this blog series).
• Compensating fully for lost wages based on the individual wage is possible in theory, but can be operationally challenging given the wide variation of earnings. This is why in most cases sponsors choose to instead compensate participants for their time and effort, providing a reasonable and standardized rate across all participants. This is a more practical and equitable approach, though it may not fully offset every participant’s financial burden.
• Standard of care medical expenses also differ based on individual insurance plans, and participation in a study may impact those benefits. It’s essential that standard of care costs be addressed clearly in both the consent form and consent discussions, and that participants are encouraged to check with their insurance providers about any personal financial implications of trial participation.

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How can study sites push back when the study stipends are too low for intensive procedures like MRIs, frequent blood draws, overnight stays, and cognitive testing?

We recognize that it can be challenging for any single site to make drastic changes to the overall trial budget. However, much like any other component of budget negotiations, sites can be most effective by presenting data on the associated costs of these procedures for participants, and where possible, presenting information on retention challenges associated with these procedures if adequate financial support is not provided. 

Ultimately, It is in the best interest of the study sponsor to provide sufficient financial support to the participant to prevent that individual from dropping out of the study on account of the financial burden. It may be useful to put this scenario in terms that your counterpart(s) at the sponsor would understand - would they accept insufficient compensation for work they do?

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How do you manage participant payments when participants need to come in for extra study activities due to site errors?

It depends on what’s approved in the consent form. If the form specifies a payment per visit, you can typically pay for an extra visit without IRB approval for the payment itself (though the extra visit may still need to be reported for other reasons). If the consent form doesn’t address this, you may need to submit a protocol deviation for IRB approval of the additional payment.

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Is there a suggested method of payment for a stipend (such as cash, a check or a gift card)? What available tools, including reimbursement programs, have you found helpful to manage payments to participants?

There are a number of payment methods offered in a clinical trial. These include:

• Direct payment (through a participant facing platform provided by a trial vendor)
• Digital payments (through the relevant digital options in the trial country, such as Venmo, Paypal, Zelle, Revolut, and more)
• Direct deposits to the participants’ bank account
• Prepaid reloadable debit cards provided by a trial vendor
• Gift cards for specific retailers or general use
• Paper checks

As mentioned above, when choosing a payment method, it is important to prioritize (1) optionality for participants, as different participants will have different preferences and needs for payment methods, (2) a short turnaround time between the out of pocket expense and receiving the payment, and (3) ensuring there are no fees to participants for using the payment method.

Sponsors should provide several payment options, to ensure they accommodate the needs of different patients. They should also push to ensure payments have no hidden fees - prepaid debit cards, for example, often have fees in their “fine print” of Terms & Conditions, that reduce the actual amount participants receive. Gift cards can also create challenges, especially if they’re limited to specific retailers, carry expiration dates, or lose value over time. In some cases, they carry the same risks as cash if lost. Other payment methods, such as cash, require patients to wait a long time to get reimbursed - which not all participants can afford. 

Accounting for these considerations and ensuring optionality puts the decision in the hands of the participant, ensuring they are able to receive the payments provided to them.

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For clinical study participants who receive government assistance and do not have resources to pay for expenses up front, how can they be supported? Is it acceptable to provide these participants with gift cards? Can patient advocacy groups who receive donations from the sponsor pay for the participation expenses?

The easiest way to cover trial expenses with no out of pocket and without it being labeled as taxable income, is to directly pay for the expense, working with a participant management platform where sponsors fund the expenses (e.g., rides, hotel, flights, etc.) upfront. This type of payment for the participants expenses is labeled as Reimbursement, and therefore has no implication to taxable income or to participants’ eligibility for welfare benefits. 

Gift cards are also an option for advancing payment, but they require a process to substantiate the expense after payment, to prevent the payment from being labeled as taxable income.

Connecting a participant with a resource that can help that individual fund their participation is also appropriate. Nonprofits or advocacy groups (often disease-specific) offer financial support to patients who meet their criteria, so long as funds are available.

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Is it permissible for a site to offer clinic-branded merchandise to a participant who prefers not to receive monetary compensation?

Gifts of minimal value are not ethically problematic. You could document this in a note to file about declining the payment if the swag is less than the value of the declined payment. However, it is important to understand why the individual is declining payment. In many cases, this type of merchandise is not a replacement for expense reimbursement (but it can be a nice additional gesture).

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Up Next

Some of the questions mentioned above touch on the tax implications of payments. We’ll dive deeper into this topic in part 3 of this series - stay tuned. If you would like to learn more on this topic, or how Mural Health can support your next trial please get in touch with us at sales@muralhealth.com.